Presented  by 
A.  R.  Hinterpohl,  D.  0« 


COLLEGE  OF  OSTEOPATHIC   PHYSICIANS 
AND  SURGEONS  •  LOS  ANGELES,  CALIFORNIA 


THE  [SURGICAL  TREATMENT 
OF  NON-MALIGNANT  AFFEC- 
TIONS OF  THE  STOMACH1 


CHARLES  GREENE  CUMSTON,  M.D. 


GEORGES  PATRY,   M.D. 

LECTURERS    AT   THE    UNIVERSITY   OF   GENEVA   AND    MEMBERS 
OF   THE   SURGICAL    SOCIETY   OF   SWITZERLAND 


WITH   AN   INTRODUCTION  BY 

SIR  BERKELEY  G.   A.   MOYNIHAN, 

K.C.M.G.,  G.B.,  M.S., 

PROFESSOR   OF   CLINICAL   SURGERY.   UNIVERSITY   OF   LEEDS 


PHILADELPHIA 
J.  B.  LIPPINCOTT  COMPANY 

LONDON  :  WILLIAM  HEINEMANN  (MEDICAL  BOOKS)  LTD. 


Printed  in  England. 


SIR  BERKELEY  MOYNIHAN, 

K.C.M.G.,  C.B.,  M.S., 

IN  RECOGNITION  OF  HIS  MASTERLY  WORK  IN  THE 

DOMAIN    OF     ABDOMINAL    SURGERY, 

THIS  BOOK  IS  DEDICATED 


PREFACE 

THE  surgical  treatment  of  non-malignant  affec- 
tions of  the  stomach  is  and  has  been  one  of  the  most 
studied  questions  in  medicine  for  the  past  twenty- 
"x  five  years.     The   bibliography  is   imposing  by  its 
n  vastness  ;  and  nevertheless,  in  spite  of  all  the  many 
^  discussions,  this  chapter  of  gastric  pathology  is  not 
tv  yet  closed.     It  still  offers — at  least  in  its  details— 
•  much  obscurity  ;  not  only  do  divergences  of  opinion 
exist  between  the  physician  and  surgeon  in  respect 
-^  to  operative  indications,  but  surgeons  themselves 
x  are  not  in  absolute  accord  as  to  the  merits  and 
.demerits  of  various  surgical  procedures. 

For  this  reason  we  have  thought  it  useful  to  group 
q  and  study  the  data  acquired  during  the  past  twenty 
i  years  in  the  domain  of  gastric  surgery.  Our  aim  has 
^  been  to  treat  those  questions  which  appear  to  us 
^  interesting  to  both  the  physician  and  surgeon,  other- 
^•wise  put,  to  make  the  monograph  a  medico -surgical 
^  treatise  on  the  subject. 

.     The  details  of  differential  diagnosis  that  are  to  be 
~  found  in  any  book  on  gastric  diseases  have  been  given 
^  little  space  ;   likewise  the  details  of  operative  tech- 
nique have  been  omitted  for  the  same  reason.    We 
N*  shall  study  successively  the  operative  indications, 
\the  results  obtained  and  the  special  indications  of 
v  each  procedure  in  stenosis,  ulcer,  gastric  dystopia  and 


viii  PEEFACE 

dilatation,  nervous  dyspepsias,  disturbances  of  the 
gastric  secretion,  tuberculosis,  syphilis  and  traumatic 
lesions  of  the  stomach. 

We  believe  in  the  fallacy  of  statistics ;  therefore 
very  few  are  given.  The  literature  consulted  in  the 
preparation  of  the  book  has  been  so  enormous  that 
to  append  a  bibliography  of  the  subjects  treated 
would  unduly  increase  the  size  of  the  volume ;  hence 
it  has  been  omitted. 

Lastly,  the  book  represents  the  combined  experi- 
ence of  an  American  surgeon  well  versed  in  Conti- 
nental methods  and  a  Continental  surgeon  fully 
conversant  with  Anglo-Saxon  surgery  and  practice. 
This  international  team  work  is,  perhaps,  the  most 
original  part  of  the  book. 

CHAELES  GEEENE  CUMSTON. 
GEOEGES  PATEY. 

GENEVA,  1921. 


INTRODUCTION 

A  BOOK  of  this  kind  is  very  necessary.  The  litera- 
ture of  gastric  ulcer  is  considerable,  but  much  of  it 
was  written  before  the  days  when  the  truths  of  the 
pathology  of  the  living  were  revealed  by  the  work  of 
the  surgeon.  The  discrepancy  between  the  older 
teaching  with  regard  to  ulceration  of  the  stomach 
and  the  newer  opinions  promulgated  by  the  surgeons 
is  serious.  Gastric  ulcer  is  not  easily  recognised  by  a 
study  of  the  clinical  symptoms  alone  nor  by  these 
in  conjunction  with  the  chemical  changes  in  the 
stomach  contents  ;  it  is  not  commoner  in  women 
than  in  men,  and  is  infrequent  in  young  girls  ;  it  is 
not  often  ushered  in  by  an  attack  of  hsematemesis, 
and  bleeding  is  infrequent  in  cases  in  which  an  ulcer 
is  found  when  an  operation  is  performed.  The 
symptoms  of  gastric  ulcer  are  closely  mimicked  by 
other  diseases,  and  operations  are  carried  out  not 
infrequently  upon  the  stomach  when  no  local 
justification  for  them  is  to  be  found.  The  truth  about 
the  disease  is  obscured  by  the  older  writings  based 
largely  upon  clinical  experience,  without  the  proof 
being  offered  that  a  veritable  lesion  in  the  stomach 
existed. 

There  are  wide  divergences  of  opinion  between 
physician  and  surgeon  concerning  the  need  for  sur- 
gical treatment  in  non-malignant  diseases  of  the 


x  INTRODUCTION 

stomach.  Neither  the  physician  nor  the  surgeon 
undertakes  adventures  into  the  territory  of  the 
other  with  that  frequency  which  would  be  a  benefit 
to  both,  and  so  far  as  the  details  of  surgical  treat- 
ment are  concerned  there  is  nothing  approaching 
unanimity  among  surgeons  whose  experience  is 
considerable.  A  fresh  and  intimate  study  of  the 
whole  subject  is  urgently  needed,  and  consequently 
a  work  of  this  kind,  written  by  surgeons  who  have 
devoted  great  talents  and  a  wealth  of  care  to  a  close 
study  of  these  affections  and  their  treatment,  will 
be  eagerly  welcomed  in  every  land. 

BERKELEY  MOYNIHAN. 


CONTENTS 


CHAP.  PAGE 

PREFACE vii 

INTRODUCTION   .......  ix 

I.     OPERATIVE  PROCEDURES 1 

II.    GASTROENTEROSTOMY 15 

III.  PULMONARY  COMPLICATIONS  AND  OPERATIVE  SHOCK  45 

IV.  THE  RESECTIONS 54 

V.    THE  STENOSES  .......  70 

VI.    GASTRIC  ULCER  :    ITS  ETIOLOGY,  PATHOGENESIS, 

PATHOLOGY  AND  CLINICAL  TYPES    .         .         .118 
VII.     THE  OPERATIVE  INDICATIONS  IN  TYPICAL  GASTRIC 

ULCER 153 

VIII.    THE    INDICATIONS    FOR    OPERATION   IN   HJBMOR- 

RHAGIC  ULCER 206 

IX.    PAINFUL  GASTRIC  ULCER 254 

X.    PERFORATED  GASTRIC  ULCER      .         .                 .  264 

XL    GASTRIC  DYSTOPIAS 284 

XII.    THE  NERVOUS  DYSPEPSIAS          ....  299 

XIII.  DILATATION  OF  THE  STOMACH     ....  304 

XIV.  TUBERCULOSIS  AND  SYPHILIS  OF  THE  STOMACH     .  310 
XV.    DISTURBANCES  OF  SECRETION     .         .         .         .316 

XVI.    TRAUMATIC    AFFECTIONS  :     CONTUSION,    WOUNDS 

AND  FOREIGN  BODIES  IN  THE  STOMACH   .         .  326 

INDEX  339 


CHAPTER  I 

OPERATIVE   PROCEDURES 

THE  operations  to  which  recourse  is  had  in  the 
treatment  of  non-malignant  affections  of  the  stomach 
are  very  numerous.  Some  of  them  have  fallen  into 
complete  disuse,  but  for  all  that  are  still  interesting ; 
and  some  unquestionably  should  be  brought  forth 
from  their  oblivion,  because  in  certain  cases,  although 
perhaps  rare,  they  may  still  render  good  service. 

Operations  on  the  stomach  have  been  divided 
into  two  large  classes,  whose  characters  are  not  as 
distinctive  as  was  supposed  a  few  years  ago.  The 
palliative  operations,  such  as  divulsion  and  dilatation 
of  the  pylorus,  the  pyloroplastic  procedures  or 
gastroduodenostomy,  gastrojejunostomy  and  gastro- 
enterostomy,  are  all  applicable  to  pyloric  stenosis,  the 
oldest  recognised  gastric  lesion.  The  gastroplastic 
operations  and  the  gastroanastomoses  belong  to  the 
same  type  of  operation  as  the  preceding  techniques, 
and  are  indicated  in  mediogastric  stenosis. 

The  various  types  of  gastrostomy,  gastrofixation 
and  gastroplication  have  special  indications.  Finally, 
jejunostomy  and  duodenostomy,  although  not  belong- 
ing to  gastric  surgery,  are  not  devoid  of  interest, 
because  their  most  manifest  indications  are  to  be 
found  in  non-malignant  diseases  of  the  stomach. 

Exclusion  of  the  pylorus,  to  which  little  attention 


S.T. 


2  SUEGICAL  TREATMENT 

has  been  given  in  general,  has  not  been  practised 
frequently,  but,  as  we  shall  see,  it  certainly  merits 
being  introduced  into  current  practice. 

Among  the  so-called  radical  operations  are  com- 
prised all  the  typical  and  atypical  resections,  simple 
excision,  annular  resections  and  pylorectomies. 

We  shall  follow  this  classification  in  our  description, 
but  shall  reserve  the  operation  of  gastroenterostorny 
for  a  special  chapter.  This  procedure,  which  has 
undergone  numerous  changes,  is  by  far  the  most 
important  of  all ;  and,  for  this  reason,  we  have  con- 
sidered it  necessary  to  examine  the  successive  im- 
provements made  in  its  technique  with  considerable 
detail,  and  by  giving  it  a  special  chapter  we  shall 
be  able  to  compare  it  to  the  other  operations. 

Dilatation  of  the  Pylorus. — Also  called  divulsion  of 
the  pylorus.  This  procedure  was  one  of  the  first 
attempts  made  to  overcome  pyloric  stenosis,  it  having 
been  carried  out  for  the  first  time  by  Loretta  in  1882. 
A  temporary  gastrostomy  was  first  made  a  few  centi- 
metres above  the  pylorus,  and  the  stenosis  was  then 
dilated  by  the  fingers  introduced  through  the 
gastrostomy  opening.  This  technique  presented 
serious  risk  of  infecting  the  peritoneum,  so  Hahn,  in 
1885,  proposed  to  effect  dilatation  by  invaginating 
the  wall  of  the  stomach.  He  discarded  this  procedure 
after  a  time,  which  was  taken  up  by  Paul  in  1892, 
and  afterwards  was  described  in  detail,  with  some 
improvement  in  the  technique,  by  Jaboulay  in 
1893. 

A  simple  procedure  offering  little  danger,  it  was 
bound  to  please  at  first,  and  hence  was  a  rival  of 


OPERATIVE  PROCEDURES  8 

gastroenterostomy  for  several  years.  Unfortunately, 
its  favour  was  fleeting,  and  for  a  number  of  years  it 
has  not  been  heard  of. 

Mayo-Robson  resorted  to  a  procedure  which  is 
very  similar  to  simple  dilatation,  but,  instead  of 
abandoning  the  pylorus  after  divulsion,  a  ring  of 
bone  was  inserted  in  the  lumen  of  the  pylorus,  which 
kept  the  lumen  patent  for  some  time.  This  pro- 
cedure did  not  give  any  better  results  than  those 
obtained  by  Loretta,  Hahn,  Paul  and  Jaboulay,  as 
might  be  expected. 

Pyloroplasty. — This  procedure  consists  of  enlarging 
the  lumen  of  the  pylorus  by  a  plastic  method  in  cases 
of  stenosis  from  an  old  fibrous  cicatrix.  Heinecke 
caused  his  procedure  to  be  published  by  Frohmiiller 
in  1886,  and  in  the  following  year  Mikulicz  slightly 
modified  the  original  technique.  The  latter  surgeon 
became  one  of  the  warm  partisans  of  this  operation, 
to  which  he  promptly  attached  his  name.  Some 
years  later  it  was  performed  by  Pearce- Gould,  who 
introduced  it  into  England  and  likewise  attached  his 
name  to  it. 

Several  other  surgeons  tested  the  operation  and 
added  some  unimportant  changes  in  technique,  the 
details  of  which  are  hardly  worth  mentioning.  For 
several  years  it  was  regarded  as  preferable  to  gastro- 
enterostomy, but  little  by  little  it  was  abandoned,  as 
the  opinion  was  generally  held  that  particularly 
favourable  anatomical  circumstances  were  necessary 
in  order  to  carry  out  the  procedure  with  any  degree 
of  security,  and  even  then  it  hardly  gave  any 

better  results  than  gastroenterostomy.  Mikulicz  alone 

•  I 


4  SUEQICAL  TREATMENT 

remained  its  supporter,  and  still  was  performing  it 
not  very  many  years  ago. 

Gastrotomy. — This  operation  consists  of  an  incision 
made  in  the  stomach  wall,  and,  apart  from  the 
removal  of  foreign  bodies,  the  operation  has  few 
indications.  Defontain,  Henri  Delageniere  and 
Mariere  have  referred  to  other  indications  of  gastro- 
tomy  than  for  foreign  bodies,  and,  in  company 
with  these  writers,  Monprofit  has  envisaged — (1)  ex- 
ploratory gastrotomy,  which  is  simply  a  preliminary 
step  of  some  other  operation,  usually  directed  against 
haemorrhage,  such  as  curettage  or  cauterisation  of  the 
ulcer  or  ligature  of  a  vessel  on  the  internal  surface 
of  the  organ  ;  (2)  gastrotomy  for  the  removal  of 
foreign  bodies  or  in  cases  of  acute  gastric  dilatation 
(Hoffmann,  1904).  It  is,  according  to  Monprofit, 
the  operation  of  choice  in  cases  of  volvulus  of  the 
stomach  when  this  cannot  be  reduced  on  account  of 
the  dilatation  of  the  organ. 

The  technique  of  gastrotomy  is  self-evident  and 
requires  no  explanation.  Some  writers  have,  how- 
ever, proposed  fixing  the  edges  of  the  gastric  incision 
to  the  edges  of  the  abdominal  incision  in  order  to 
avoid  the  flow  of  septic  gastric  contents  into  the 
peritoneal  cavity. 

It  should  also  be  noted  that  when  doing  exploratory 
gastrotomy  it  may  be  well  in  difficult  cases  to  pass 
the  hand  into  the  retro-omental  space  through  an 
opening  made  in  the  mesocolon.  This  manoeuvre  will 
allow  one  to  make  a  more  careful  exploration  of  the 
posterior  wall  of  the  stomach.  Nevertheless,  regard- 
less of  these  indications,  gastrotomy  certainly  remains 


OPERATIVE  PROCEDURES  5 

an  uncommon  operation,  and  in  itself  offers  very  little 
interest. 

Gastro lysis. — In  reality  often  one  of  the  simplest 
gastric  operations,  gastrolysis  is  not  one  of  the  first 
procedures  in  the  history  of  gastric  surgery.  Fre- 
quently combined  with  other  procedures,  such  as 
gastroenterostomy,  it  was  performed  per  se  only  in 
1888  by  Loretta.  This  surgeon  was  the  first  to 
recognise  the  importance  of  bands  and  adhesions 
seated  on  the  gastric  walls,  especially  at  the  pylorus. 
He  was  imitated  by  Codilla,  Tricomi,  Lange, 
Lauenstein,  Landerer  and  Robinson,  and  from  1893 
the  cases  operated  on  by  this  procedure  become  too 
numerous  to  mention. 

There  can  be  no  regular  technique  for  an  operation 
which  depends  solely  upon  the  anatomical  circum- 
stances present,  these  being  essentially  variable 
according  to  the  case.  Usually  of  utmost  simplicity, 
this  procedure  may  give  rise  to  most  surprising 
results.  Frequently  it  is  not  necessary  to  com- 
bine some  other  operation  with  it,  such  as  gastro- 
enterostomy, although  some  surgeons  deny  any 
favourable  effect  to  be  derived  from  the  mere 
releasing  of  an  adhesion  often  very  insignificant 
in  itself. 

Gastropexy. — The  idea  of  fixing  a  stomach  in  the 
state  of  ptosis  dates  back  to  the  time  when  the  kidney 
and  uterus  were  being  treated  by  various  types  of 
pexias,  but  gastropexy  was  not  done  until  1895,  when 
Duret,  of  Lille,  performed  it  for  the  first  time.  Later 
on  Rovsing  made  some  changes  in  the  technique, 
and  these  were  completed  by  Jonnesco  by  the 


6  SURGICAL  TREATMENT 

addition  of  plication  and  anastomoses  which  entirely 
transformed  the  original  operation. 

Other  writers  have  likewise  described  technical 
changes  in  Duret's  operation.  Thus  Kammerer,  in 
1900,  fixed  the  stomach  to  the  liver,  Hartmann  to  the 
diaphragm,  and  we  come  to  indirect  gastropexias, 
which,  let  it  be  said,  gave  very  unsatisfactory  results. 
We  mention  these  procedures  merely  from  the 
view-point  of  history.  Kammerer  tried  to  shorten 
the  gastro-hepatic  ligament,  Denis  fixed  the  lesser 
omentum  to  the  parietal  peritoneum,  while  Hengel- 
Beyler  simply  shortened  the  lesser  omentum  without 
fixation.  This  operation,  which  was  done  in  1897,  was 
not  published  until  1899,  and  was  again  the  object  of 
several  papers  by  Beyler  in  1903  and  1904.  Coffey, 
in  1902,  proposed  fixing  the  great  omentum  to  the 
anterior  parietal  peritoneum  with  the  object  of  giving 
indirect  support  to  the  dislocated  stomach. 

There  is  also  another  indirect  procedure  that  was 
performed  by  the  late  Professor  Girard.  This  con- 
sists of  fixation  of  the  transverse  colon  to  the  anterior 
abdominal  wall.  The  greater  curvature  is  supported 
by  the  intermediary  of  the  gastrocolic  ligament,  but 
precaution  must  be  taken  to  fix  the  lesser  curva- 
ture as  well  to  the  gastrohepatic  ligament  by  a  few 
sutures. 

After  having  interested  surgeons,  it  was  found  that 
these  various  procedures  did  not  give  the  results 
anticipated,  so  that  for  some  years  they  were  only 
exceptionally  performed.  We  shall  show,  when 
speaking  of  gastroptosis,  how  very  limited  are  the 
indications  for  these  procedures. 


OPERATIVE   PROCEDURES  7 

Gastroplication.  —  This  operation  is  somewhat 
similar  to  gastrofixation.  The  technique  was  devised 
at  about  the  same  time,  and  followed  the  same  fate  as 
fixation.  In  1891  Bircher  performed  gastroplication 
for  the  first  time,  which  was  received  with  considerable 
favour.  It  unquestionably  gave  good  results  at  the 
hands  of  several  surgeons,  among  them  Baudoin, 
Weir,  Brandt,  Bennett,  Gueliot,  Tricomi  and  Borelius, 
who  published  a  series  of  papers  on  the  subject  from 
1891  to  1900. 

Several  techniques  were  employed,  the  most  impor- 
tant of  which  are  briefly  as  follow  : — 

Folding  of  the  anterior  gastric  wall  by  means  of  a 
single  middle  row  of  sutures  (Bircher's  original  pro- 
cedure) or  with  two  rows  of  superimposed  sutures 
(Weir),  several  fan-shaped  folds  (Bennett),  or 
folding  on  the  anterior  and  posterior  walls  of  the 
stomach  combined  with  multiple  invaginations 
(Brandt). 

This  operation  and  gastropexy  were  at  length 
supplanted  by  gastroenterostomy,  but  it  is  only  just 
to  say  that  in  some  cases  of  simple  dilatation  of  the 
stomach  without  neuromotor  phenomena  or  pyloric 
spasm  these  operative  procedures  give  excellent 
results  even  when  gastroenterostomy  has  failed  to 
relieve  the  condition.  Gastroplication,  although 
infrequently  employed  at  present,  should  not  be 
completely  discarded. 

Gastroplasty. — Gastroplasty  is  intended  to  over- 
come the  mediogastric  stenosis  of  bilocular  stomach. 
In  principle  similar  to  Heinecke's  pyloroplasty,  it 
was  not  done  until  long  after  the  latter  operation. 


8  SUKGICAL  TREATMENT 

Bardleben  performed  it  for  the  first  time,  with  success, 
in  1899. 

In  the  literature  since  published  some  cases  of 
mediogastric  stenosis  treated  by  this  procedure  are 
reported,  but  they  are  few  in  number.  As  we  shall 
show,  the  indications  for  this  operation  are  very 
limited,  and  it  is  only  natural  that  the  procedure  has 
not  assumed  the  importance  that  one  might  have 
expected. 

Gastroanastomosis. — In  1894  Woelfler  proposed 
gastroanastomosis  for  the  same  operative  indications 
as  gastroplasty.  This  procedure  consists  of  creating 
a  stoma  between  the  two  gastric  pouches  in  bilocula- 
tion.  It  has  given  good  results,  although  it  is  rarely 
employed.  In  1900  Watson  proposed  a  modification 
in  Woelfler's  original  technique  consisting  of  a  pre- 
liminary plication  of  the  stomach.  This  procedure 
was  successfully  used  by  some  operators,  among 
whom  may  be  mentioned  von  Eiselsberg,  Schwartz, 
Hochenegg  and  Lauenstein. 

Gastroduodenostomy. — This  procedure  consists  of 
creating  a  stoma  between  the  stomach  and  duodenum; 
it  unquestionably  presents  great  advantages,  but 
unfortunately  the  anatomical  conditions  necessary 
for  its  performance  are  rarely  favourable.  Indicated 
in  pyloric  stenosis,  it  is  rare  that  the  obstacle  is 
sufficiently  localised  to  allow  easy  approximation 
of  the  two  organs.  However,  these  favourable  cir- 
cumstances may  be  met  with,  especially  when  the 
pylorus  is  stenosed  by  a  constricting  band  or  an 
adhesion  causing  an  acute  bend  of  the  duodenum, 
as  is  encountered  in  cases  of  old  cholecystitis  with 


OPERATIVE  PROCEDURES  9 

extension  of  the  inflammatory  process  to  the 
pylorus. 

It  was  in  these  circumstances  that  Villar  first 
performed  this  operation,  which  bears  his  name  in 
France,  while  some  time  later  Finney,  of  Baltimore, 
resorted  to  an  operation  similar  in  principle,  but  which 
nevertheless  differs  in  its  details  from  Villar's  tech- 
nique. Later  on  Jaboulay  in  France  and  Kummell 
in  Germany  proposed  similar  procedures.  Finally, 
Lerich  developed  an  operation  of  the  same  kind,  but 
which  differed  from  the  others  in  a  very  special 
technique.  Generally  known  by  the  name  of  Finney's 
operation  outside  of  France,  gastroduodenostomy  can 
only  be  resorted  to  in  exceptionally  favourable  cases, 
and  when  the  right  anatomical  conditions  exist  it 
gives  really  excellent  results. 

Exclusion  of  the  Pylorus. — Exclusion  of  the  pylorus 
can  only  be  unilateral,  as  a  bilateral  operation  would 
expose  the  patient  to  all  the  dangers  accruing  from 
a  closed  cavity  with  contents  that  clearly  must  be 
septic.  The  principle  of  the  procedure  is  to  separate 
the  pylorus  or  pyloric  region  from  the  rest  of  the 
stomach.  The  gastric  cavity  diverts  its  contents  into 
the  intestine  through  a  stoma,  while  the  secretions 
of  the  pyloric  region  flow  off  through  the  duodenum. 

Typical  exclusion,  sometimes  called  von  Eisels- 
berg's  exclusion,  consists  of  a  transversal  division 
of  the  stomach  above  the  pylorus,  after  which  both 
sides  of  the  section  are  closed.  This  procedure, 
which  is  absolutely  certain  in  its  results  from  the 
view-point  of  rest  of  both  the  pylorus  and  duodenum, 
is  long  and  sometimes  laborious  to  carry  out.  There- 


10  SUKGICAL  TREATMENT 

fore  an  attempt  has  been  made  to  obtain  the  same 
result  at  less  expense.  Thus  W.  S.  Mayo  simply 
makes  a  plication  of  the  pylorus  with  interrupted 
non-perforating  sutures  placed  in  the  anterior  wall 
of  the  duodenum.  This  is  known  by  the  name  of 
blockage  of  the  pylorus. 

Doyen  performed  this  operation  years  ago,  but  was 
unable  to  arouse  any  interest  in  it  among  surgeons. 
The  operation  is  simple  and  very  rapidly  carried  out, 
but  the  results  obtained  are  not  permanent.  Cases 
are  recorded  in  which  the  pylorus  became  patent 
again  after  a  variable  lapse  of  time,  so  that  the  gastric 
contents  no  longer  passed  through  the  stoma. 

Moynihan  has  also  described  a  procedure  by 
infolding  of  the  ulcer  of  the  duodenum  which  is  not 
unlike  the  procedure  in  question.  Acting  on  a  spot 
where  the  ulcer  has  caused  morbid  changes  in  the 
walls  or  where  a  cicatricial  process  already  predisposes 
to  stenosis,  there  will  be  more  likelihood  of  obtaining 
a  prolonged  result,  if  not  a  permanent  one. 

In  his  animal  experiments  Clumsky  ligated  the 
pylorus,  and  this  procedure  has  been  resorted  to  by 
several  operators,  some  using  silk,  others  a  thin  strip 
of  omentum,  the  round  ligament  of  the  liver  or  fine 
strips  of  fascia.  Girard  several  times  performed  a 
plastic  procedure  of  the  type  of  Heinecke's  pyloro- 
plasty,  only  in  an  inverted  sense.  He  simply 
dissected  up  the  mucosa  far  enough  to  obtain  a 
sufficient  narrowing.  Biondi  adds  resection  of  a  cuff 
of  mucosa  between  two  ligatures  to  this  technique. 
The  latter  operation  certainly  appears  to  offer  every 
security  in  regard  to  the  ultimate  results,  but  it  is  a 


OPERATIVE  PROCEDURES  11 

question  whether  it  is  really  preferable  to  von  Eisels- 
berg's technique.  Theoretically  it  is  pleasing,  but  in 
practice  it  may  be  very  difficult  to  carry  out.  When 
the  ulcer  is  on  the  posterior  aspect  of  the  organ,  dis- 
section of  the  mucosa  may  be  very  difficult,  or  even 
impossible. 

Therefore,  having  ourselves  performed  nearly  every 
variety  of  exclusion,  we  feel  prepared  to  say  that, 
unless  the  condition  of  the  patient  is  a  contra-indica- 
tion,  von  Eiselsberg's  procedure  is  unquestionably 
the  one  of  choice.  When  a  permanent  occlusion  is 
not  desired  or  when  the  patient's  condition  demands 
a  rapid  interference,  the  simpler  means  of  blockage 
of  the  pylorus,  following  Mayo's  technique,  should  be 
preferred  to  all  others. 

We  would  add  that  von  Eiselsberg's  procedure 
can  be  modified  by  only  closing  the  pyloric  side  and 
implanting  the  gastric  side  into  the  jejunum,  following 
the  technique  of  resection,  which  is  daily  becoming 
more  in  vogue.  However,  it  would  seem  from  recent 
comment  that  this  procedure  exposes  the  patient 
to  peptic  ulcer  more  than  any  other. 

Exclusion  does  not  only  act  by  protecting  a  pyloric 
or  duodenal  ulcer  from  mechanical  irritations  resulting 
from  the  passage  of  the  gastric  contents.  Several 
writers  have  shown  that  the  gastric  mucosa  of  the 
excluded  region  undergoes  a  marked  degree  of 
atrophy,  the  result  being  a  large  decrease  of  HC1. 
Taking  this  fact  into  consideration,  we  would  advise 
making  the  exclusion  several  centimetres  above  the 
pylorus.  In  opposition  to  the  ideas  propounded  by 
some  operators,  we  venture  to  believe  that  the  tech- 


12  SURGICAL  TREATMENT 

nique  is  easier,  because,  although  there  is  the  disadvan- 
tage of  having  a  longer  divided  section  of  the  stomach 
to  suture,  this  disadvantage  is  largely  compensated  for 
by  the  greater  ease  with  which  infolding  can  be 
accomplished.  We  have  frequently  had  the  oppor- 
tunity of  excluding  the  entire  pyloric  antrum  even 
in  cases  of  ulcer  of  the  lesser  curvature. 

The  recent  experiments  carried  out  by  R.  Lewisohn 
on  the  value  of  pyloric  exclusion  need  to  be  briefly 
referred  to  here.  A  suture  gastroenterostomy,  with 
and  without  pyloric  exclusion,  was  done  on  dogs. 
Two  days  later  300  c.c.  of  a  2  per  cent,  thionin 
solution  were  injected  into  the  stomach  through  a 
tube.  The  dogs  were  killed  the  next  day.  The 
difference  in  the  colouring  of  the  duodenum  in  the 
excluded  and  non-excluded  specimens  was  very 
obvious.  When  exclusion  had  been  done  the  mucosa 
and  jejunum  distal  to  the  stoma  were  dark  green. 
The  duodenum  showed  only  a  slight  trace  of  colour. 
Consequently  the  exclusion  caused  practically  all 
the  thionin  to  be  driven  directly  into  the  jejunum 
without  passing  the  pylorus.  Berg's  technique  of 
pyloric  exclusion  is  not  complete  for  fluids,  but  it 
prevents  food  from  passing.  The  specimens  in  which 
exclusion  was  not  done  showed  an  evenly  dark  green 
stain  of  the  stomach,  duodenum  and  jejunum. 
Evidently  the  solution  had  passed  about  evenly 
through  the  pylorus  and  stoma. 

It  may  be  very  advantageous  that  pyloric  exclusion 
is  only  temporary  and  that  after  healing  of  the  ulcer 
the  normal  passage  through  the  pylorus  is  partially 
restored,  because  it  has  been  shown  that  HC1  will  be 


OPERATIVE   PROCEDURES  13 

neutralised  much  less  efficiently  if  it  passes  directly 
through  the  stoma  into  the  intestine  than  if  it  passes 
via  the  duodenum.  Lewisohn  believes  that  the 
diarrhoea  occurring  after  gastroenterostomy  is  prob- 
ably due  to  the  action  of  insufficiently  neutralised 
HC1  on  the  intestinal  mucosa. 

Jejunostomy  and  Duodenostomy. — These  proce- 
dures do  not  belong  to  surgery  of  the  stomach,  strictly 
speaking.  They  are,  however,  interesting,  because 
they  have  indications  of  a  purely  gastric  nature. 
Analogous  in  principle,  they  are  among  the  oldest 
operations  resorted  to  for  malignant  and  non- 
malignant  affections  of  the  stomach.  At  first  almost 
solely  employed  in  cases  of  pyloric  cancer  when 
resection  was  regarded  as  too  dangerous,  it  was  soon 
recognised  that  much  advantage  could  be  derived 
from  these  procedures  in  hsemorrhagic  or  perforating 
ulcer,  extensive  perigastritis,  etc. 

Braune,  in  1876,  was  the  first  to  propose  duode- 
nostomy,  and  attempted  to  reach  the  duodenum  via 
the  lumbar  route.  Langenbuch  was  the  first  to  carry- 
out  the  operation  on  man,  but  he  had  the  good  sense 
to  do  it  through  an  abdominal  incision.  After  him 
Southam,  Billroth,  Tuffier  and  Jessett  resorted  to  the 
operation,  and  although  it  was  never  frequently 
performed,  cases  were  reported  from  time  to  time. 

The  technique  offers  nothing  in  particular,  and  we 
know  of  no  interesting  modifications  to  note. 

Jejunostomy  is  simpler,  surer  and  much  more 
frequently  employed  than  duodenostomy.  The  first 
procedure  was  described  by  Surmay  in  1877,  and  a 
year  later  he  published  a  paper  in  which  he  mentioned 


14  SUEGICAL  TREATMENT 

the  indications  for  the  operation.  In  1883  Robertson 
performed  the  second  recorded  jejunostomy  for  a 
non-malignant  pyloric  stenosis  giving  rise  to  pro- 
found cachexia.  After  this  the  operation  was  more 
frequently  performed,  especially  in  England,  where 
it  appears  to  have  enjoyed  a  certain  vogue. 

Then  Maydl  and  von  Eiselsberg  became  convinced 
partisans  of  this  procedure  and  published  several 
papers  setting  forth  its  advantages.  Since  then 
several  French  and  German  writers  have  given  the 
indications  and  technique  of  this  procedure.  Un- 
questionably this  operation  will  become  more  and 
more  frequent,  especially  in  cancer,  but  also  in  non- 
malignant  affections  in  which  it  is  of  the  utmost 
importance  to  place  the  stomach  in  absolute  and 
prolonged  rest. 

The  changes  of  technique  have  been  many. 
Glaudscheff  (thesis,  Geneva,  1908;  has  described 
twenty-four  different  procedures.  We  would  merely 
remark  that  the  best  methods  are  the  simplest,  and 
among  the  more  complicated  techniques  the  second 
one,  devised  by  Maydl,  alone  seems  to  offer  some 
advantages. 


CHAPTER  II 

GASTROENTEROSTOMY 

GASTROENTEROSTOMY  consists  of  creating  a  direct 
communication  between  the  stomach  and  intestine. 
In  opposition  to  gastroduodenostomy,  it  is  also  called 
gastrojejunostomy,  the  stoma  being  made  in  the 
first  portion  of  the  jejunum.  Performed  for  the  first 
time  by  Woelfler  in  1882,  its  d6but  was  rather  difficult 
and  gave  little  encouragement.  However,  several 
surgeons  were  not  discouraged  by  the  unsuccessful 
results  at  first  obtained,  and  by  animal  experimenta- 
tion they  finally  perfected  the  procedure  to  such  an 
extent  that  the  results  surpassed  their  most  sanguine 
expectations. 

The  number  of  procedures  which  were  successively 
proposed,  often  with  only  minor  technical  changes,  is 
considerable,  and  few  operations  have  been  the 
object  of  so  much  literature.  The  reason  for  this  is 
that  this  operation,  so  simple  in  theory  and  of  such 
easy  technique  on  the  cadaver,  is  in  reality  infinitely 
more  complex  than  was  at  first  supposed  ;  a  number 
of  technical  details  here  assume  a  much  greater 
importance  than  in  similar  operations,  such,  for 
example,  as  the  enteroanastomoses.  It  was  only 
progressively  and  on  account  of  the  unfortunate 
consequences — and  they  were  many — that  the  defec- 
tive functional  results  were  overcome,  while  at  the 


16  SUKGICAL  TREATMENT 

same  time  an  exact  appreciation  was  made  of  the 
dangers  to  be  avoided,  as  well  as  the  importance  to 
be  attached  to  minor  details.  Hence  it  was  only 
gradually  that  gastroenterostomy  finally  became  the 
well-regulated  operation  that  it  is  to-day,  giving  per- 
fect functional  results  in  the  hands  of  operators 
accustomed  to  intestinal  surgery. 

This  security  in  the  proper  functions  of  a  gastro- 
intestinal anastomosis  has  therefore  been  acquired 
by  long  years  of  study  and  by  the  collaboration  of  a 
host  of  operators  of  all  countries,  each  one  making  a 
change  or  improving  some  step  in  the  operation.  It 
would  be  out  of  the  question  to  mention  all  those  who 
have  studied  gastroenterostomy.  We  shall  simply 
describe  the  general  principles  of  the  improvements 
successively  made  in  the  original  technique,  with  an 
attempt  to  give  them  not  so  much  in  chronological 
order  as  in  a  rational  one,  that  is  to  say,  by  following 
the  object  aimed  at  by  surgeons. 

We  shall  show  the  enormous  amount  of  work  that 
has  been  accomplished  during  the  relatively  short 
lapse  of  time  separating  Woelfler's  first  operation  and 
the  present-day  technique,  which  now  seems  to  have 
been  settled  in  all  its  details. 

To  write  the  history  of  gastroenterostomy  will  in 
reality  be  a  description  of  the  various  stumbling- 
blocks  met  with  by  surgeons  and  to  study  in  what  way 
and  by  what  operative  procedures  they  were  finally 
able  to  avoid  them.  The  dangers  of  gastroenteros- 
tomy and  the  disastrous  results  sometimes  ensuing 
after  this  operation  have  been  the  object  of  very 
complete  studies,  the  most  important  being  Naveau's 


GASTROENTEROSTOMY  17 

thesis  (Paris,  1904),  inspired  by  Monprofit,  Clumsky's 
paper  and  Tavel's  study,  which  is  a  complete  mono- 
graph on  "  reflux  "  in  gastroenterostomy. 

The  dangers  and  disadvantages  of  gastroenteros- 
tomy can  be  divided  into  two  classes  : — 

(1)  Those  exclusively  encountered  after  this  opera- 
tion, such  as  (1)  the  vicious  circle  and    (2)  peptic 
ulcer  of  the  jejunum. 

(2)  Those   common  to   abdominal  operations   in 
general,  but  which  find  in  gastroenterostomy  par- 
ticularly  favourable   conditions   for  their   develop- 
ment, and  from  this  fact  have  resulted  the  modifica- 
tions made  in  its  technique.    The  most  important 
are  post-operative  pulmonary  accidents  and  arterio- 
mesenteric  occlusion. 

Vicious  Circle. — This  is  unquestionably  the  most 
frequent  complication  of  gastroenterostomy,  especi- 
ally if  we  envisage  as  such  all  cases  of  vomiting  and 
regurgitation,  even  when  occurring  late  in  con- 
valescence from  operation,  as  did  Tavel.  It  was  the 
vicious  circle  that  contributed  the  most  to  discourage 
the  first  operators  who  attempted  the  procedure. 

Although  Woelfler's  first  case  was  a  success,  it  waa 
quite  different  in  the  case  of  those  surgeons  who 
imitated  him.  Thus  Billroth  lost  his  first  patient 
on  the  tenth  day  following  the  interference  from 
incoercible  vomiting.  Autopsy  showed  that  the  bad 
functional  result  of  the  gastro-intestinal  anastomosis 
was  due  to  the  fact  that  the  stoma  connecting  the 
stomach  with  the  anastomosed  intestinal  loop  was 
larger  than  the  stoma  in  the  efferent  branch.  The 
gastric  contents  were  therefore  emptied  into  the 

l.T.  O 


18  SURGICAL  TREATMENT 

duodenal  branch,  and  had  no  tendency  to  follow 
their  normal  jejunal  course. 

In  1882  Kocher  also  lost  his  first  case  from  vomit- 
ing which  could  not  be  controlled,  even  by  a  second 
operation.  Autopsy  showed  that  the  coils  of  intestine 
dragged  on  the  edges  of  the  stoma,  and  that  by  this 
traction  a  kind  of  valve  was  formed.  This  valve,  being 
placed  in  the  wrong  direction,  prevented  the  stoma 
from  fulfilling  its  functions. 

Lauenstein  also  had  an  unsuccessful  result  in  the 
following  year  which  he  attributed  to  the  same 
cause.  In  order  to  avoid  dragging  on  the  anasto- 
mosis, he  selected  the  first  intestinal  loop  that 
offered  itself  and  that  could  be  approximated  to  the 
stomach  without  traction.  Fortunately  for  gastro- 
enterostomy,  Rydygier  and  Liicke  (1883)  had  better 
results,  and  after  this  date  the  operation  began  to  be 
done  much  more  frequently.  Various  procedures  were 
devised,  and  it  was  finally  proved  that  there  was  not  a 
single  cause  of  vicious  circle,  but  that,  on  the  contrary, 
there  were  many,  and  often  very  slight,  causes. 

We  cannot  cite  each  instance  in  particular.  We 
will  classify  and  study  them  according  to  their  cause, 
and  in  this  way  we  can  review  the  principal  pro- 
cedures which  were  successively  proposed  for  avoid- 
ing them  and  thus  come  to  the  various  types  of 
operation  still  resorted  to  at  present. 

The  causes  of  vicious  circle  generally  admitted  and 
demonstrated  at  autopsy  of  the  cases  reported  in 
literature  are  very  numerous.  This  serious  complica- 
tion may  be  due  to  the  following : — 

(1)  The  anastomotic  stoma,  according  to  its  position, 


GASTROENTEROSTOMY  19 

size,  direction,  shape  and   union  of   the  intestine 
and  stomach. 

(2)  The  intestinal  loop,  according  to  its  length, 
direction,  compression  and  respective  position  of  its 
afferent  and  efferent  branches. 

(3)  Special     circumstances :     immediate,     gastro- 
intestinal atony  ;   late,  bands  and  adhesions. 

The  Stoma. — Position.  When  Woelfler  performed 
the  first  gastroenterostomy — at  the  instigation  of  his 
assistant  Nicoladoni — he  made  the  anastomosis  that 
seemed  to  him  the  most  simple  and  at  the  same  time 
the  most  rational.  Therefore  he  took  the  first  loop 
of  jejunum,  and  bringing  it  up  over  the  omentum  and 
transverse  colon,  he  sutured  it  to  the  anterior  gastric 
wall .  Being  the  simplest ,  this  technique  was  naturally 
the  easiest,  as  the  suturing  could  be  done  outside  of 
the  peritoneal  cavity. 

But  very  soon  it  was  found  that  this  anterior 
anastomosis  offered  very  serious  disadvantages.  Not 
only  the  route  taken  by  the  jejunal  loop  was  com- 
plicated and  was  exposed  to  become  strangulated 
by  torsion  or  to  compress  the  colon,  but  the  anasto- 
mosis on  the  anterior  gastric  wall  was  not  placed  at  a 
declivous  part.  Therefore  it  was  assumed  that  the 
stomach  only  emptied  through  the  stoma  by  over- 
flow, and  some  surgeons,  among  them  von  Hacker, 
feared  that  the  stoma  might  become  occluded  by 
pressure  against  the  anterior  abdominal  wall. 

In  1885  von  Hacker  proposed  posterior  transmeso- 
colic  gastroenterostomy.  He  believed  that  this  pro- 
cedure offered  the  great  advantage  of  placing  the 
stoma  at  a  declivous  point ;  it  also  did  away  with  the 

c  2 


20  SURGICAL  TREATMENT 

long  circuitous  route  that  the  intestinal  loop  was 
forced  to  follow  in  order  to  join  the  stomach  in 
Woelfler's  procedure. 

This  operation,  which  was  certainly  more  difficult 
to  carry  out,  was  not  at  first  successful,  but  little 
by  little  it  was  adopted  by  a  large  number  of  operators, 
who  regarded  it  as  the  method  of  choice.  Czerny  was 
one  of  the  first  to  recommend  it,  and  both  he  and  his 
assistant  Petersen  obtained  excellent  results  and 
published  several  papers  advocating  its  use.  After 
1890  the  great  question  of  gastric  surgery  was 
whether  Woelfler's  or  von  Hacker's  procedure  should 
be  adopted.  Most  surgeons  were  in  favour  of  the 
latter  method  in  France,  England,  Italy,  Switzerland 
and  Germany.  On  the  other  hand,  a  few  operators 
remained  faithful  to  anterior  anastomosis,  but  the 
majority  did  not  favour  it ;  they  completed  it  by 
some  secondary  operation,  such  as  Braun's  entero- 
anastomosis  or  the  more  complicated  procedures  of 
Doyen  or  Roux's  Y  anastomosis,  as  will  be  seen  later 
on.  Kocher  was  one  of  the  very  few  who  as  late  as 
1911  returned  to  simple  anterior  anastomosis  after 
having  employed  von  Hacker's  gastroenterostomy, 
and  Monprofit  at  this  time  was  also  doing  anterior 
Y  gastroenterostomy.  Mikulicz  also  continued  to  do 
anterior  anastomosis,  but  he  completed  the  operation 
by  an  enteroanastomosis  whenever  the  stomach 
showed  signs  of  even  slight  atony.  Von  Eiselsberg 
occasionally  did  the  anterior  operation,  but  combined 
it  with  enteroanastomosis. 

Therefore  it  can  be  said  that  von  Hacker's  posterior 
procedure  little  by  little  supplanted  Woelfler's 


GASTROENTEROSTOMY  21 

anterior  method.  The  results  were  infinitely  better, 
and  what  seems  to  affirm  the  superiority  of  posterior 
gastroenterostomy  is  that  its  technique  has  remained 
exactly  the  same,  while  in  the  case  of  anterior  anasto- 
mosis many  changes  and  improvements,  quite  as 
varied  as  they  are  complicated,  have  been  devised. 

The  position  of  the  stoma  at  the  posterior  aspect 
of  the  stomach  gave  better  results  in  practice,  but 
this  was  not  the  only  cause  of  the  success  of  von 
Hacker's  procedure.  The  declivous  point  which 
seemed  to  be  the  ideal  position  for  the  stoma  has,  in 
fact,  lost  much  of  its  former  importance.  It  was 
only  at  a  much  later  date  that  it  was  discovered  that 
gastroenterostomy  did  not  merely  drain  the  stomach, 
which  was  regarded  as  an  inert  cavity.  The  import- 
ance of  peristalsis  of  the  organ  played  a  large  part ; 
the  pouch  whose  drainage  is  to  be  assured  is  far 
from  being  an  inert  cavity,  and,  on  the  contrary,  is 
endowed  with  active  contractions  taking  place  in  a 
definite  direction. 

Kelling's  researches  and  the  more  recent  ones 
carried  out  by  Tuffier  and  Reclus,  Delbet  and  Guibe, 
concerning  the  functions  of  the  stoma  in  patients 
with  a  patent  pylorus,  by  means  of  animal  experi- 
ments and  radioscopy  in  man,  fully  confirm  the 
capital  importance  of  gastric  contraction.  It  is 
perfectly  apparent  that  the  stomach  of  an  operated 
patient  does  not  empty  itself  like  a  basket  with  a 
hole  in  it ;  it  can  only  evacuate  its  contents  by  the 
action  of  peristalsis,  and  the  question  arises  as  to  how 
the  contractions  act. 

If  the  successive  shapes  assumed  by  the  stomach  be 


22  SURGICAL  TREATMENT 

followed  on  the  radioscopic  screen  in  its  attempts  to 
expel  the  bismuth  meal,  it  will  be  seen  that  the 
pylorus  drops  so  that  it  is  exactly  in  the  axis  of  the 
stomach.  It  is  only  after  this  displacement  of  the 
gastric  sphincter  that  by  successive  waves  the  con- 
tractions of  the  organ  push  the  gastric  contents  in  the 
same  direction,  causing  them  to  follow  the  main  axis 
of  the  organ,  which  has  become  rectilinear  by  dropping 
of  the  pylorus. 

It  is  evident  that,  following  the  change  in  shape 
and  direction  of  the  stomach,  the  stoma,  being  remote 
from  the  pylorus,  will  no  longer  be  at  the  most 
declivous  part  of  the  gastric  cavity.  Thus,  for 
example,  a  stoma  placed  at  the  middle  portion  of  the 
greater  curvature,  the  extreme  point  of  dilatation  at 
the  time  anastomosis  is  done,  will  be  far  from  the 
declivous  point  when  the  stomach  attempts  to  empty 
its  contents  by  peristaltic  contractions.  In  reality 
the  most  declivous  point  will  be  in  the  immediate- 
region  of  the  pylorus. 

Moreover,  as  Guibe  has  remarked,  the  stoma  can 
only  be  a  lateral  opening,  and  it  is  well  known  that 
such  lateral  openings  are  generally  defective — iliac 
colostomy,  for  example.  To  remedy  this,  the  anasto- 
mosis would  have  to  be  placed  as  far  as  possible 
opposite  the  axis  of  the  stomach,  at  the  point  where 
all  the  forces  of  the  organ  converge,  otherwise  put 
as  near  the  pylorus  as  possible. 

Hence  the  theory  of  the  declivous  point  has  lost  its 
value,  and  at  present  attempts  are  being  made  to 
place  the  stoma  as  near  to  the  normal  physiological 
outlet  of  the  stomach  as  can  be  done.  True  it  is  that 


GASTKOENTEROSTOMY  23 

this  is  not  always  possible,  because  the  entire  pre- 
pyloric  region  is  often  involved  by  the  lesion  requiring 
operation.  An  anastomosis  cannot  be  made  in  good 
conditions  in  these  indurated  cicatricial  tissues.  We 
shall  examine  further  on,  when  speaking  of  exclusion 
of  the  pylorus,  the  best  means  for  assuring  the 
regular  functions  of  the  stoma  in  spite  of  unfavour- 
able circumstances.  But  as  a  general  rule,  when  one 
has  the  choice,  the  stoma  should  be  made  near  the 
pylorus  in  the  posterior  gastric  wall.  When  the 
posterior  gastric  wall  is  not  accessible,  the  Y  procedure 
should  be  preferred  to  Woelfler's  early  technique. 

Size  of  the  Stoma. — Complications  resulting  from 
a  too  small  or  a  too  large  stoma  have  not  been 
studied  very  closely.  Most  surgeons  make  what 
they  call  an  "  easily  permeable  anastomosis  "  ;  some 
merely  call  attention  to  the  importance  that  should 
be  given  to  this  special  point  in  the  technique 
without  giving  any  indications. 

In  his  study  on  gastroenterostomy,  Clumsky,  out 
of  a  total  of  550  collected  cases,  only  found  forty-four 
in  which  exact  indications  were  given  in  regard  to 
the  size  of  the  stomata.  He  found  that  in  eleven 
cases  where  the  stoma  measured  less  than  3  centi- 
metres seven  resulted  in  defective  function,  and  finally 
death  ensued  with  distinct  symptoms  of  stenosis. 

On  the  other  hand,  Stansfield  and  Jaboulay  had 
little  better  results  with  stomata  measuring  from 
12  to  15  centimetres.  In  these  cases  these  observers 
several  times  noted  phenomena  of  occlusion  due  to 
the  formation  of  valves. 

At  present  most  surgeons  have  discarded  large 


24  SUEGICAL  TREATMENT 

stomata,  making  them  from  5  to  6  centimetres  long. 
We  would,  however,  remark  that  in  certain  cases,  as 
we  shall  show  further  on,  it  may  be  advantageous  to 
make  a  stoma  about  8  to  10  centimetres  in  length. 
But,  as  Clumsky  points  out,  it  is  not  only  important 
to  give  proper  dimensions  to  the  stoma,  but  one 
should  also  make  the  gastric  and  intestinal  incisions 
exactly  the  same  length.  In  order  to  do  this,  since 
the  wall  of  the  intestine  is  thinner  and  less  retractile, 
the  gastric  incision  should  be  longer  than  that  in  the 
intestine.  If  this  detail  is  neglected,  there  will  be 
more  material  on  the  jejunal  side  than  on  the  gastric 
side  when  suturing  is  completed,  and  in  order  to 
obtain  good  coaptation  one  will  be  obliged  to  make 
some  folds,  which  always  tend  to  be  the  starting-point 
of  valve  formation.  Clumsky  reports  two  cases  in 
which  vicious  circle  appeared  to  result  from  this  cause. 
Several  writers  have  insisted  on  the  necessity  of 
obtaining  exact  coaptation  of  the  edges  of  the 
incisions.  Sonnenburg,  Colzi,  Magill,  Chaput  and 
Clumsky  have  referred  to  the  danger  ensuing  from 
inexact  suturing.  Now,  although  throughout  the 
development  of  the  technique  the  importance  of 
sero-serous  sutures  was  understood,  it  was  only 
tardily  that  the  necessity  of  exact  approximation  of 
both  mucosa  was  recognised.  The  above-mentioned 
writers  point  out  that,  if  this  is  not  exact,  adhesions 
and  cicatricial  contractions  result  which  may  bring 
about  complete  occlusion  of  the  stoma.  Such 
extreme  cases  are  not  rare  ;  they  have  several  times 
been  verified  at  a  second  operation  that  had  become 
necessary. 


GASTROENTEROSTOMY  25 

Monprofit,  in  1907,  reported  a  personal  case,  and 
refers  to  two  others,  one  of  Tuffier,  another  of  Roux. 
These  cases  of  complete  occlusion  of  the  stoma  are 
well  known  to  all  surgeons  at  present,  and  we  are 
even  persuaded,  as  we  shall  show  further  on,  that 
this  cicatricial  occlusion  is  relatively  frequent  when 
the  pylorus  is  patent,  but  that  it  is  often  overlooked 
or  only  gives  rise  to  remote  disturbances  that  are  not 
correctly  interpreted. 

Direction  of  the  Gastric  Incision. — This  will  naturally 
vary  according  to  the  position  chosen  for  the  anasto- 
mosis. When  Woelfler's  technique  was  at  first 
employed,  little  attention  was  paid  to  the  direction 
of  the  incision  in  the  stomach,  and  it  was  only  at  a 
much  later  date  that  this  technical  point  was  con- 
sidered. Woelfler  advised  making  a  vertical  incision, 
that  is  to  say,  perpendicular  to  the  long  axis  of  the 
stomach.  By  so  doing  he  followed  the  indications 
dictated  by  the  anatomy  of  the  gastric  vessels. 
These  travel  upward  perpendicularly  from  the  lower 
coronary  artery  to  the  greater  curvature  to  anasto- 
mose with  the  branches  coming  from  the  superior 
coronary  artery.  For  Woelfler  this  procedure  had 
the  advantage  of  respecting  the  vessels,  thus  avoiding 
the  development  of  haematoma  or  haemorrhage  along 
the  suture  line.  On  the  other  hand,  the  direction 
given  to  the  incision  did  not  appear  to  have  any  very 
considerable  influence  over  the  ultimate  functionating 
of  the  stoma,  so  that  the  majority  of  surgeons 
adopted  Woelfler's  technique,  and,  like  him,  they  made 
the  gastric  incision  perpendicular  to  the  long  axis 
of  the  organ. 


26  SURGICAL  TREATMENT 

By  degrees,  however,  certain  operators,  fearing 
valve  formation,  preferred  making  the  incision 
parallel  to  the  greater  curvature.  They  were  in  still 
greater  fear  of  the  vicious  circle  than  of  the  minor 
complications  accruing  from  small  haemorrhages. 

Moynihan  and  Mayo-Robson,  being  more  pre- 
occupied by  the  direction  of  the  intestinal  loops  than 
that  of  the  incision,  made  an  oblique  opening  in  the 
stomach  parallel  to  the  axis  of  the  loop  to  be  anasto- 
mosed. Thus  Moynihan  made  it  oblique  from  left 
to  right  and  from  above  downward. 

According  to  Petersen,  who  gave  much  thought  to 
the  anatomy  of  the  root  of  the  jejunum  and  the 
posterior  gastric  wall,  a  normal  oblique  direction 
should  be  given  to  the  intestinal  loop,  while  later  on 
he  also  concluded  that  the  gastric  incision  should 
likewise  be  oblique.  Hartmann  practised  an  oblique 
incision  from  above  downward  and  from  left  to  right. 

Although  those  few  operators  discussed  this  tech- 
nical detail  of  the  operation,  it  must  be  admitted  that 
the  great  majority  of  papers,  even  those  dealing  with 
the  operative  technique  in  all  its  details,  did  not 
refer  to  the  stoma.  Moreover,  the  conditions  being 
different  in  each  case,  the  surgeon  will  not  always 
have  the  choice,  and  consequently  will  be  obliged  to 
follow  the  indications  dictated  by  the  anatomical 
conditions  present.  But  in  1909  Dahlgren  published 
a  paper  in  which  he  insisted  upon  the  oblique  direc- 
tion that  should  be  given  to  the  gastric  incision. 
He  maintained  that  either  perpendicular  or  trans- 
versal incisions  present  the  same  disadvantage, 
namely,  that  of  being  of  necessity  parallel  to  one  of 


GASTROENTEROSTOMY  27 

the  layers  of  muscle,  since  the  latter  are  directed 
either  longitudinally  or  circularly.  An  incision  made 
parallel  to  the  direction  of  one  of  these  muscular 
layers  is  bad,  because  it  will  tend  to  contract  tightly 
during  peristalsis.  For  ordinary  latero-lateral  ana- 
stomoses an  incision  which  will  obliquely  divide  both 
muscular  layers  will  assure  sufficient  functional  work 
on  the  condition  that  it  be  long  enough  to  divide  a 
sufficient  number  of  muscular  fasciculi. 

The  great  majority  of  operators  make  a  simple 
gastric  and  intestinal  incision,  and  do  not  always  seem 
to  attach  much  importance  to  this  special  point.  On 
the  contrary,  some  attempt  to  obtain  the  formation 
of  a  valve  has  been  made  in  order  to  avoid  spur 
formation,  which  is  the  cause  of  vicious  circle  :  the 
valve  facilitates  the  passage  of  the  gastric  contents 
into  the  efferent  branch.  In  1884  Kocher  recom- 
mended a  crescent-shaped  incision,  which  was 
disastrous  :  it  favoured  the  development  of  adhesions 
and  secondary  cicatricial  contraction,  as  was  made 
evident  by  two  cases  reported  by  Hetzel,  the  patients 
dying  from  complete  occlusion  of  the  stomata. 

If,  on  the  other  hand,  in  order  to  avoid  cicatricial 
contraction,  the  length  of  the  incision  is  increased  so 
that  it  is  more  than  one  half  the  length  of  the  diameter 
of  the  intestine,  the  opening  will  be  quite  sufficient, 
but  the  valve  is  apt  to  functionate  in  the  opposite 
direction,  thus  favouring  passage  of  the  gastric 
contents  into  the  afferent  branch.  Consequently  this 
procedure,  which  had  given  such  great  hope  from 
experimental  work  on  the  cadaver,  was  quickly  given 
up  in  practice. 


28  SURGICAL  TREATMENT 

A  little  later  Doyen  made  an  incision  with  very 
complicated  suturing,  too  complicated,  indeed,  to  be 
adopted.  Chaput  advised  an  H-shaped  incision  with 
a  double  valve,  a  procedure  that  never  became 
current.  Still  other  writers,  Sikow  and  Poncet 
among  others,  endeavoured  to  direct  the  gastric 
contents  into  the  efferent  branch  by  means  of 
complex  incisions  and  suturing,  but  their  efforts  were 
without  avail. 

Since  1900  the  various  valve  procedures  have  been 
found  to  be  illusory,  and  all  attempts  in  this  direction 
have  been  abandoned.  With  the  same  idea  in  view, 
Sonnenburg  tried  to  assure  better  functionating  of 
the  stoma  by  invaginating  the  gastric  wall  into  the 
intestine.  This  ingenious  procedure  is  briefly  as 
follows : — 

(1)  Incision  of  the  stomach  3  centimetres  long. 

(2)  Fixation  of  the  intestine  to  the  edge  of  this 
incision  by  four  to  six  sutures. 

(3)  Incision  of  the  intestine  3  centimetres  long. 

(4)  Temporary  incision  of  the  intestine  1  centi- 
metre  long    at    about    3    centimetres    below    the 
first. 

(5)  Passing  of  silk  threads  through  the  intestinal 
incision  up  to  the  second  opening  and  fixation  at  this 
level. 

(6)  Closure  of  the  temporary  intestinal  incision. 

(7)  Exact  sero-serous  fixation  of  the  stomach  to 
the  intestine. 

Sonnenburg  thus  obtained  invagination  of  the 
gastric  wall  into  the  intestinal  loop  ;  the  invaginated 
portion  was  cone-shaped,  which  theoretically  should 


29 

assure  the  direction  of  the  flow  into  the  efferent 
branch.  The  results  were  not  better  than  those 
obtained  by  other  procedures,  and  consequently  the 
operation  was  given  up.  Faure's  procedure,  which 
is  almost  identical,  gave  no  better  results.  Similar 
to  these  two  procedures  are  the  complicated  opera- 
tions devised  by  Rutkowski  and  Witzel,  who  per- 
formed gastroenterostomy  combined  with  gastros- 
tomy.  The  gastrostomy  tube  passes  through  the 
stomach  and  enters  far  into  the  afferent  branch. 
According  to  these  observers,  the  advantages  of  the 
method  are : — 

(1)  To     begin    feeding    immediately    after     the 
operation. 

(2)  To  give  a  normal  direction  of  the  future  gastric 
flow  by  means  of  temporary  canalisation. 

Of  all  these  procedures  not  one  has  shown  itself 
superior  to  the  others,  and  not  one  has  given  results 
that  in  any  way  compensate  for  the  length  and 
difficulty  of  the  technique.  For  this  reason  other 
more  simple  procedures  have  been  adopted,  so  that 
the  valve  operations  are  now  a  part  of  the  history  of 
gastroenterostomy. 

Direction  of  the  Intestinal  Loop. — In  his  first  opera- 
tion Woelfler  simply  brought  an  intestinal  loop  into 
contact  with  the  stomach  without  paying  attention 
to  the  direction  given  to  it,  peristalsis  or  the  distance 
of  the  stoma  from  the  ligament  of  Treitz.  He 
consequently  did  an  anti-peristaltic  anastomosis, 
or  at  least  this  is  what  we  are  given  to  understand. 
Those  who  followed  him  did  the  same,  so  that  the 
results  were  for  the  most  part  disastrous.  It  waa 


30  SURGICAL  TREATMENT 

only  two  years  later  that  Woelfler  himself  pointed 
out  the  importance  of  intestinal  peristalsis. 

The  first  operator  to  obtain  satisfactory  results 
in  a  really  important  series  of  gastroenterostomies 
was  Liicke,  who  out  of  eight  operations  only  had  one 
death  from  vicious  circle.  As  his  assistant  Rockwitz 
showed  in  a  paper  published  at  the  time,  these 
fortunate  results  were  obtained  by  placing  the  loop 
in  the  normal  direction  so  that  its  physiology  was  not 
interfered  with.  Liicke's  results — 12*5  per  cent, 
mortality — were  decidedly  superior  to  those  obtained 
in  other  clinics,  which  showed  a  mortality  of  57  per 
cent,  out  of  a  total  of  twenty-one  cases.  In  order 
to  be  sure  of  the  right  direction  of  peristalsis,  Rock- 
witz advised  resorting  to  Nothnagel's  test,  namely, 
that  of  exciting  the  intestine  with  a  crystal  of  sea  salt. 

Most  surgeons  then  admitted  the  correctness  of  the 
Liicke-Rockwitz  technique,  but  they  preferred  to 
ascertain  the  direction  of  peristalsis  by  first  finding 
the  origin  of  the  jejunum,  and  not  by  Nothnagel's 
test,  because  this  had  been  the  means  of  leading 
Lauenstein  astray  in  one  case.  Shortly  after  Rock- 
witz's  paper  appeared  Peham  pointed  out  that  the 
most  simple  direction,  that  ordinarily  given  to  the 
intestine,  was  in  reality  isoperistaltic,  while  in  1899 
Hartmann  and  Soupault  made  the  same  remark. 
After  this  the  majority  of  surgeons  attributed  great 
importance  to  isoperistalsis,  which  was  finally  recog- 
nised to  be  one  of  the  primordial  principles  of  success 
in  gastroenterostomy. 

Length  of  the  Anastomotic  Loop. — In  his  first 
paper  Woelfler  advised  making  the  stoma  at  from 


GASTROENTEROSTOMY  31 

40  to  50  centimetres  from  the  emergence  of  the 
jejunum,  but  it  was  not  long  before  other  data  were 
accepted,  because  it  was  feared  that  if  the  loop  were 
too  short  there  was  danger  of  dragging  on  the  edges 
of  the  stoma  or  the  production  of  compression  on  the 
colon.  Now,  as  has  been  said,  Rockwitz  (1888)  pub- 
lished the  first  encouraging  series  of  cases  of  gastro- 
enterostomy  and  advised  simply  selecting  a  loop  that 
could  be  anastomosed  without  dragging.  He  also 
explained  the  good  results  obtained  as  being  partially 
due  to  the  abdominal  incision  being  made  as  short  as 
possible,  taking  the  highest  loop  presenting,  or  at 
least  the  one  that  appeared  to  be,  without  trying  to 
ascertain  what  loop  was  being  anastomosed. 

This  blind  procedure  was  not  generally  accepted ; 
it  gave  bad  results,  especially  at  the  hands  of 
Obalymsky,  Augens,  Wassiliew  and,  lastly,  Lauen- 
stein.  The  latter's  case  is  the  most  striking  example 
of  the  danger  of  not  exactly  recognising  what  loop 
is  to  be  anastomosed,  as  well  as  the  distance  of  the 
stoma  from  Treitz's  ligament.  Eleven  days  after  the 
operation  the  patient  died  from  emaciation  without 
vomiting,  but  with  a  diarrhoea  that  could  not  be 
controlled  by  any  treatment.  Autopsy  revealed  the 
technical  mistake  :  the  stoma  was  just  30  centi- 
metres above  the  ileo-csecal  valve. 

Therefore  operators  attempted  to  discover  the 
means  by  which  the  exposed  loop  could  be  recognised, 
and  Socin's  simple,  and  at  the  same  time  most 
logical,  procedure  for  this  purpose  was  rapidly 
adopted.  Already  in  1884  Socin  advised  raising  up 
the  omentum  and  transverse  colon  and  then  seizing 


32  SUKGICAL  TREATMENT 

the  first  intestinal  loop  that  presented  itself  just  below 
the  insertion  of  the  mesocolon.  If  the  loop  is 
found  to  be  fixed  in  the  depth  of  the  abdomen,  it 
will  be  sure  to  be  the  first  loop  of  the  jejunum,  and  it 
will  then  be  easy  to  measure  the  length  considered 
necessary  for  making  the  anastomosis. 

From  the  start  Woelfler's  gastroenterostomy 
appeared  to  be  defective  on  account  of  the  length  that 
one  felt  obliged  to  give  the  anastomotic  loop,  so  that 
several  operators  tried  to  find  a  more  direct  way  by 
avoiding  going  round  and  over  the  omentum  and 
transverse  colon.  In  1884  Courvoisier  showed  the 
road  that  should  be  followed  in  order  to  directly 
connect  the  stomach  with  the  intestine.  He  per- 
formed the  first  anterior  transomental  mesocolic 
anastomosis,  thus  greatly  decreasing  the  length  of 
the  loop.  Then  von  Hacker  proposed  his  procedure, 
which  has  remained  classic,  and  which  is  still  more 
direct,  namely  posterior  transmesocolic  anastomosis. 
Finally,  Billroth,  Brenner,  Bramann  and  Hassler 
performed  anterior  transomental  mesocolic  gastro- 
enterostomy with  some  small  technical  modifications 
of  little  interest.  It  need  only  be  said  that  these 
procedures,  which  were  quite  as  complicated  as,  if  not 
more  so  than,  von  Hacker's  gastroenterostomy,  were 
employed  by  those  who  devised  them,  but  their 
results  were  not  sufficiently  brilliant  to  encourage 
others  to  use  them. 

In  1897  Doyen  proposed  inserting  the  greater 
omentum  into  the  retrogastric  cavity  with  the  object 
of  decreasing  the  length  of  the  loop,  as  well  as  of  doing 
away  with  compression  or  dragging  on  the  sutures. 


GASTBOENTEROSTOMY  33 

Although  this  method  was  proclaimed  to  be  techni- 
cally correct  in  certain  cases  by  Clumsky  and  others, 
it  was  not  carried  out  by  other  operators,  and  the 
necessary  length  to  give  to  the  intestinal  loop  was 
especially  considered  and  discussed  in  regard  to  trans- 
mesocolic  gastroenterostomy. 

In  his  original  paper  von  Hacker  advised  com- 
prising about  20  to  25  centimetres  of  the  jejunum 
in  order  to  avoid  dragging  on  or  kinks  or  volvulus 
of  the  anastomosis.  Although  he  advised  this  length, 
he  usually  himself  took  a  shorter  loop,  as  he 
admitted  later  on,  when  Petersen,  after  a  careful 
anatomical  study  of  the  parts,  maintained  that  the 
loop  should  be  as  short  as  possible  in  order  to  obtain 
the  best  functional  results  from  the  anastomosis. 
He,  in  fact,  remarked  that  the  fixed  insertion  of  the 
jejunum  to  Treitz's  ligament  was  normally  situated 
higher  up  than  the  greater  curvature  of  the  stomach. 
Therefore  if  as  short  a  loop  as  possible  is  selected, 
that  is  to  say,  coming  directly  from  Treitz's  ligament 
to  the  anastomosis,  without  any  bend,  the  efferent 
and  afferent  branches  cannot  assume  a  parallel 
position  to  each  other :  one  will  be  above  with  an 
oblique  direction  from  above  downward  and  from 
left  to  right,  which  will  also  place  it  in  the  correct 
position  for  isoperistalsis,  while  the  other  branch  will 
be  frankly  vertical  and  running  from  above  downward. 

The  average  distance  separating  Treitz's  muscle 
from  the  posterior  aspect  of  the  stomach,  where 
the  anastomosis  is  generally  made,  is,  according  to 
Petersen,  from  8  to  10  centimetres  ;  therefore  this 
should  be  the  length  of  the  loop.  According  to 

S.T.  D 


34  SURGICAL  TREATMENT 

Petersen,  any  bend  or  kink  of  the  loop  will  be  avoided 
by  this  means,  and,  above  all,  the  branches  will  not 
be  parallel,  this  being  one  of  the  frequent  causes 
of  vicious  circle  which  have,  as  we  shall  show,  greatly 
preoccupied  those  who  have  done  much  to  advance 
gastric  surgery. 

Most  operators  adopted  Petersen's  opinion  and 
made  the  anastomosis  with  as  short  a  loop  as  possible 
in  von  Hacker's  procedure,  which,  of  course,  is  the 
only  technique  now  under  consideration  ;  Kelling 
was  about  the  only  one  at  the  time  who  did  not 
admit  the  advisability  of  a  short  loop  and,  on  the 
contrary,  recommended  one  some  40  centimetres 
long.  He  believed  that  it  was  dangerous  to  take  a 
loop  as  short  as  possible,  that  is  to  say  just  long 
enough  to  be  brought  without  too  much  traction  from 
the  jejunal  fold  to  the  point  where  the  anastomosis 
was  to  be  made,  because  the  anatomical  relationship 
changes  much  more  than  might  be  supposed  accord- 
ing to  the  degree  of  repletion  either  of  the  stomach 
or  the  intestine. 

On  the  other  hand,  Kelling  did  not  admit  that  the 
position  of  the  loops  as  described  by  Petersen  could 
prevent  the  formation  of  a  spur.  Parallelism  of  the 
branches  of  the  loop  is  less  favourable  for  the  forma- 
tion of  a  valve  than  a  too  long  incision  or  the  drag- 
ging on  the  edges  of  the  anastomosis  by  a  loop  that 
is  too  short.  Other  than  for  these  theoretical  views, 
we  do  not  know  of  a  case  in  which  a  short  loop  has 
been  supposed  to  have  been  the  cause  of  vicious  circle 
or  even  of  bad  functions  of  the  stoma.  Schwartz  is 
the  only  one  who  has  published  a  case  of  gastro- 


35 

enterostomy  where  the  patient  died  a  few  days  after 
operation  following  incoercible  vomiting,  which  was 
not  even  controlled  by  doing  Braun's  enteroanasto- 
mosis.  Autopsy  showed  that  the  procedure  had 
been  correctly  carried  out  :  the  functions  of  the 
stoma  were  perfect,  but  it  was  thought  that  the 
jejunal  loop  was  too  short,  provoking  vomiting  by 
continuous  dragging  on  the  stomach. 

In  1902  Steinthal  published  an  interesting  study 
of  some  cases  operated  on  with  as  short  a  loop  as 
possible.  He  compared  the  results  with  those 
obtained  by  Korte,  who  had  remained  faithful  to  the 
primordial  principle  and  used  a  loop  40  centi- 
metres long.  The  comparison  was  decidedly  in 
favour  of  the  Czerny-Petersen  technique.  The  latter 
procedure  was  quickly  adopted  by  most  surgeons  who 
employed  von  Hacker's  operation.  Not  only  Czerny 
and  his  following,  but  Hartmann,  Mayo-Robson  and 
Moynihan,  were  warm  in  its  favour.  Those  who 
employed  a  long  loop  did  so  with  the  object  of  avoid- 
ing kinks  and  parallel  branches.  From  the  simple 
procedures  operations  in  two  steps  became  fashion- 
able, and,  lastly,  Roux's  and  Doyen's  Y-shaped 
techniques  were  employed. 

The  most  simple  was  fixation  of  the  afferent 
branch  on  the  gastric  wall  in  order  to  give  a  per- 
manent direction  to  the  loop  chosen  and  to  avoid 
bends  at  the  spot  where  the  anastomosis  had  been 
made.  Madra  was  the  first  to  develop  this  idea. 
In  1891  he  advised  suspending  the  loop,  not  only  the 
afferent,  but  the  efferent  branch  as  well,  with  a 
few  sero-serous  sutures  over  the  extent  of  5  to  6 


36  SURGICAL  TREATMENT 

centimetres.  In  1895  Lauenstein  recommended 
simple  suspension  of  the  afferent  branch  only,  while 
in  1898  Peham  proposed  the  same  technique,  and, 
finally,  in  1899  Kappeler  recommended  double  sus- 
pension in  a  paper  in  which  he  wrote  as  if  he  were  the 
originator  of  this  technical  detail. 

But  these  various  procedures  were  very  soon  found 
to  be  perfectly  useless.  Clumsky  pointed  out  that 
there  was  danger  of  having  two  spurs  instead  of  one 
from  bending  at  the  point  of  fixation.  At  first  used 
by  some  surgeons,  they  were  soon  given  up,  while 
other  procedures  appeared  upon  the  scene.  Already 
in  1890  Lauenstein  had  resorted  to  complementary 
anastomosis  by  anastomosing  the  afferent  branch 
with  a  branch  of  the  jejunum  "  seated  as  high  up  as 
possible."  In  1892  Jaboulay  and  Braun  each  pro- 
posed an  analogous  procedure,  but  for  greater  security 
they  placed  the  anastomosis  between  the  afferent  and 
efferent  branches.  In  this  way  they  did  not  exclude 
the  alkaline  secretions  brought  by  the  afferent  branch 
from  a  portion  of  the  intestine  oftentimes  quite 
considerable. 

The  chief  danger  of  this  technique  was  that 
peritonitis  ensued  from  the  double  opening  in  the 
intestine.  In  1896  Lauenstein,  the  promoter  of  this 
technical  detail,  discarded  it,  having  had  several 
cases  of  peritoneal  infection  due  to  it.  Braun 
advised  his  method  as  a  palliative  procedure,  and 
decided  to  do  it  only  when  post-operative  vomiting 
led  to  the  suspicion  of  a  vicious  circle. 

Other  surgeons  did  enteroanastomosis  in  all  cases 
where  anatomical  conditions  prevented  them  from 


GASTROENTEROSTOMY  37 

carrying  out  von  Hacker's  gastroenterostomy,  such 
as  extensive  callous  tissue  formation  or  adhesions  too 
tough  to  separate.  Thus  Lindner  usually  resorted 
to  Woelfler's  anterior  gastroenterostomy  combined 
with  immediate  enteroanastomosis.  Mikulicz,  who 
remained  a  partisan  of  anterior  anastomosis,  advised 
Braun's  procedure  in  all  cases  in  which  there  was  gas- 
tric atony.  Although  this  technique  was  really  service- 
able in  quite  a  number  of  cases,  it  did  not  prevent  the 
development  of  a  vicious  circle,  and  several  instances 
are  recorded  of  death  from  vicious  circle  in  spite  of 
either  immediate  or  secondary  enteroanastomosis. 

From  Braun's  operation  to  the  Y  procedure  there 
was  only  one  step  to  take,  and  this  was  done  by  Roux, 
who  was  the  first  to  carry  it  out  in  man,  although  in 
1887  Woelfler  had  tried  it  experimentally  in  dogs,  and 
Maydl  had  suggested  it  in  1892.  Moreover,  in  1897, 
Doyen,  after  having  tried  for  a  long  time  to  tighten 
the  afferent  branch  by  plication  or  simple  ligature, 
decided  to  resect  the  afferent  branch,  the  intestino- 
intestinal  anastomosis  having  been  previously  done. 
He  consequently  did  a  Y-shaped  gastroenterostomy 
combined  with  latero-lateral  anastomosis. 

Unfortunately,  these  procedures,  which  give  excel- 
lent results,  are  complicated,  twice  as  long  to  carry 
out  as  von  Hacker's  operation,  and  also  are  more 
dangerous.  Cases  of  secondary  perforation  of  the 
initial  part  of  the  vertical  branch  of  the  Y  are  not 
uncommon.  The  development  of  peptic  ulcer  of  the 
jejunum  at  this  level  is  easy  to  comprehend,  as  the 
gastric  juice,  with  all  its  acidity,  is  thrown  into  a 
part  of  the  jejunum  which  only  tolerates  alkaline 


38  SURGICAL   TREATMENT 

contents.  This  acidity  is  neutralised  in  cases  of 
simple  anastomosis  by  the  simultaneous  admixture 
of  the  alkaline  duodenal  juices  with  the  gastric 
contents  in  the  jejunum,  a  condition  which  does  not 
occur  in  the  Y-shaped  procedure. 

Nevertheless  the  Y-shaped  procedures  with  a 
terminal  (Roux)  or  lateral  (Doyen)  anterior  or 
posterior  stoma  were  in  the  past  accepted  as  methods 
of  choice  by  many  experienced  surgeons,  other  opera- 
tions being  merely  regarded  as  palliative,  only  to  be 
resorted  to  when  one  could  not  do  otherwise.  Thus 
Monprofit  was  an  enthusiastic  partisan  of  this  pro- 
cedure, and  maintained  that  it  was  the  only  one 
which  avoided  the  development  of  the  vicious  circle. 
It  was  for  this  reason  that  he  especially  recommended 
it  in  cases  of  non-malignant  stenosis,  where  it  is  all- 
important  to  obtain  perfect  functional  results. 
Pantaloni,  of  Marseilles,  and  Tavel,  of  Berne,  looked 
upon  it  as  the  surest  method,  giving  excellent  results. 
At  one  time  extensively  used  in  Prance,  the  procedure 
was  much  less  employed  in  England  and  Germany. 
In  the  statistics  published  some  years  ago  by  Mayo- 
Robson,  Moynihan,  Czerny  and  von  Eiselsberg, 
only  a  few  Y-shaped  anastomoses  are  mentioned  ; 
the  method,  therefore,  has  been  tried,  but  not  con- 
tinued, by  these  surgeons. 

We  shall  show  further  on  that  Monprofit's  opinion 
can  no  longer  be  sustained,  and  that,  on  the  contrary, 
although  in  malignant  processes  all  the  procedures 
can  be  indifferently  employed,  Y-shaped  anastomosis 
is  to  be  discarded  in  the  vast  majority  of  non-malig- 
nant affections  of  the  stomach. 


GASTROENTEROSTOMY  89 

Post-operative  Adhesions.  —  This  complication, 
which,  in  our  opinion,  is  much  more  frequent  than  is 
generally  admitted,  has  not  received  the  attention 
it  deserves,  and,  from  this  fact,  has  had  little  bearing 
on  changes  in  operative  technique.  Various  writers, 
like  Clumsky  and  Tavel,  who  have  given  much  time 
to  the  study  of  the  causes  of  reflux  in  gastroente- 
rostomy,  hardly  refer  to  it.  It  should  be  said  that 
post-operative  adhesions  have  never  to  our  know- 
ledge been  the  cause  of  serious  vicious  circle,  but  we 
feel  that  cases  of  mild  reflux  due  to  imperfect 
functional  results  are  frequently  caused  by  bands  of 
adhesions  seated  at  the  level  of  or  near  to  the 
anastomosis. 

We  have  not  found  anything  in  literature  that 
might  lead  us  to  affirm  that  there  are  any  operations 
that  predispose  to  their  formation  more  than  others. 
However,  in  searching  for  the  causes  favouring  the 
formation  of  adhesions  it  will  be  seen  that  certain 
procedures  may  create  them  more  than  others. 
Theoretically  it  should  be  admitted  that  all  the 
procedures  are  very  unequal  from  this  point  of  view. 
This  inequality  will  certainly  be  demonstrated  the  day 
that  a  sufficient  number  of  cases  shall  have  been 
collected  and  studied  for  reaching  practical  con- 
clusions. We  would,  however,  remark  that  the 
formation  of  adhesions  is  independent  of  the  operative 
technique  to  some  extent.  It  is  due  to  the  properties 
of  the  peritoneum,  especially  that  of  defence,  which 
is  variable  from  one  patient  to  another. 

Unquestionably  the  peritoneum  will  not  react  in 
the  same  fashion  in  every  case :  there  are  certain 


40  SURGICAL  TREATMENT 

patients  whose  serous  membranes  react  against 
infection  more  or  less  indifferently,  while  in  others 
they  offer  a  high  degree  of  what  we  would  call  plastic 
power.  Those  in  whom  this  plastic  power  is  highly 
developed  will  make  adhesions  with  the  greatest 
ease  and  upon  the  slightest  provocation.  Although 
recognising  that,  the  irritation  being  equal,  two 
different  peritoneums  will  react  by  an  unequal  pro- 
duction of  adhesions,  both  in  quantity  and  quality,  it 
must  likewise  be  admitted  that  the  irritation — the 
primordial  cause  of  adhesions — plays  an  important 
part. 

Reaction  of  the  serous  membrane  may  be  provoked 
by  either  mechanical  or  infectious  irritation ;  and  it  is, 
therefore,  clear  that  the  operative  procedure,  as  well 
as  the  way  of  operating,  will  be  responsible  for  the 
development  of  adhesions.  Therefore  we  conclude 
that  the  best  procedure  is  always  the  simplest,  the 
one  which  causes  the  least  trauma  to  the  gastro- 
intestinal serosa,  and  which  gives  the  least  chance 
for  oozing  of  septic  fluid  during  operation,  no  matter 
how  trifling  the  oozing  may  be. 

Adhesions  which  may  hinder  gastric  evacuation 
are  seated  on  the  anastomosed  loop,  on  the  afferent, 
but  more  particularly  on  the  efferent,  branch. 
Hence  it  is  that  the  efferent  branch  should  be 
manipulated  with  extreme  care  and  gentleness, 
avoiding  the  use  of  clamps  or  even  too  energetic 
manual  compression.  It  is  clear  that  the  Y-shaped 
anastomosis  offers  far  greater  risks  than  the  simple 
procedures  for  this  reason. 

Division  of  the  intestine,  gastric  anastomosis  and 


GASTROENTEROSTOMY  41 

intestinal  anastomosis  require  twice  the  number  of 
intestinal  clamps  that  simple  anastomosis  does,  hence 
increasing  100  per  cent,  the  causes  of  trauma,  there- 
fore secondary  adhesions  as  well.  Moreover,  division 
of  the  intestine  and  intestinal  anastomosis  are  just 
so  many  more  risks  of  infection,  undoubtedly  very 
trifling  as  far  as  the  peritoneum  is  concerned,  but 
important  on  account  of  the  resulting  adhesions. 

In  the  simpler  procedures,  like  von  Hacker's  for 
example,  the  cause  for  the  production  of  adhesions 
is  reduced  to  a  minimum  ;  two  clamps  suffice,  and 
the  single  gastro-intestinal  anastomosis  reduces  the 
risk  of  infection  to  the  strict  minimum. 

It  may  be  said  that  these  remarks  are  theoretical, 
and  this  we  readily  admit,  and  do  not  attach  too 
much  importance  to  them,  but  these  propositions 
have  not  been  given  the  attention  they  deserve,  so 
that  it  seemed  quite  in  place  to  refer  to  them.  They 
certainly  explain  the  defective  results  occurring  in 
technically  perfect  gastroenterostomies,  as  we  have 
observed  in  two  cases. 

Peptic  Ulcer  of  the  Jejunum. — This  lesion  of  the 
jejunum  is  unquestionably  one  of  the  most  serious 
complications  of  gastro  -  intestinal  anastomoses. 
Several  recent  contributions  to  the  subject  tend  to 
show  that  this  lesion  is  becoming  more  frequent. 
Although  recognising  the  necessity  of  taking  all 
possible  precautions  for  avoiding  this  complication, 
we  venture  to  believe  that  there  need  not  be  too 
much  pessimism  in  this  regard.  A  peptic  ulcer  may 
be  gastro-jejunal,  that  is  to  say,  developing  on  the 
line  of  the  anastomosis,  or  it  may  be  jejunal  in  site, 


42  SUEGICAL  TREATMENT 

that  is  to  say,  located  several  centimetres  below  the 
anastomosis. 

In  both  cases  the  lesion  is  produced  by  gastric 
juice  rich  in  HC1,  as  is  proved  by  the  rarity  of  the 
ulcer  following  operations  for  cancer.  This  chemical 
factor  in  the  development  of  the  lesion  must  never  be 
lost  sight  of,  in  order  to  avoid  its  occurrence.  Other 
etiological  factors  may  also  play  a  part  when  com- 
bined with  this  primordial  cause.  Certain  technical 
details  and  certain  peculiarities  of  various  procedures 
favour  the  formation  of  peptic  ulcer  more  than  others. 
Thus  the  Y-shaped  anastomoses  are  more  frequently 
followed  by  this  lesion  than  other  procedures  are.  In 
point  of  fact,  the  gastric  juice  is  in  contact  with  the 
intestinal  mucosa  for  quite  a  long  distance  before  it 
encounters  the  neutralising  secretions  of  the  liver 
and  pancreas.  The  mucosa  is  not  prepared  for  the 
action  of  pure  gastric  juice,  so  that  the  slightest 
erosion  may  be  the  starting-point  of  ulcer.  Moreover, 
the  further  away  one  gets  from  the  pylorus  the  less 
is  the  intestine  prepared  to  receive  acid  secretions. 
Therefore  an  anastomosis  with  a  long  loop  will  be 
more  prone  to  give  rise  to  this  lesion  than  one  with  a 
short  loop. 

Other  factors  depend,  not  upon  the  technical 
points  of  the  procedure  adopted,  but  rather  on  the 
way  in  which  one  operates.  All  useless  trauma  to  the 
intestine  is  to  be  avoided,  especially  of  the  efferent 
branch.  It  may  seem  superfluous  to  insist  on  this 
point.  Nevertheless,  when  one  watches  certain 
operators  at  work  as  well  as  the  rough  construction 
of  some  instruments  used,  it  can  be  readily  surmised 


GASTROENTEROSTOMY  43 

why  some  surgeons  consider  peptic  ulcer  a  frequent 
complication,  and  therefore  conclude  that  gastro- 
enterostomy  is  a  bad  procedure.  It  is  not  the  opera- 
tion that  is  bad,  but  the  way  in  which  the  technique 
is  carried  out. 

Important  statistics  have  shown  that  gastro- 
jejunal  ulcer  often  arises  when  Murphy's  button  has 
been  used,  or  some  other  similar  mechanical  device. 
Wilkie  has  called  attention  to  the  danger  of  non- 
absorbable  suture  material.  Silk  or  linen  thread 
may  remain  in  place  for  years,  and  has  often  been 
found  at  the  fundus  of  peptic  ulcer.  It  is  clear  that 
these  sutures  are  a  cause  of  infection  and  inflammation, 
so  that  at  present  most  surgeons  employ  only  catgut 
in  their  gastro-intestinal  work,  even  for  the  sero- 
serous  sutures. 

Finally,  both  the  operator  and  the  patient  should 
not  lose  sight  of  the  fact  that,  in  spite  of  every 
technical  precaution,  a  peptic  ulcer  is  prone  to 
develop  if  the  patient  does  not  submit  to  a  diet  for  a 
prolonged  lapse  of  time  after  operation  has  been 
done. 

Gastric  Atony. — By  itself  alone  gastric  atony  may 
seriously  compromise  the  success  of  gastroenteros- 
tomy.  Besides  acute  dilatation  of  the  stomach, 
which  may  suddenly  occur  after  any  laparotomy, 
simple  gastro-intestinal  atony  may  engender  a  true 
vicious  circle. 

In  his  detailed  study  of  vicious  circle  Clumsky 
attributes  particular  importance  to  the  contractility 
of  the  afferent  branch.  If  this  be  atonic  and  becomes 
distended  either  with  bile  or  the  development  of 


44  SURGICAL  TREATMENT 

gastric  reflux,  it  will  exercise  traction  on  the  anasto- 
mosis, at  length  giving  rise  to  a  spur  which  will 
canalise  the  gastric  contents  in  this  direction. 

Gastro-intestinal  atony  cannot  always  be  foreseen 
at  the  time  of  the  interference  ;  hence  this  complica- 
tion has  not  given  rise  to  any  technical  improvement. 
From  the  view-point  of  operation  the  Braun- 
Jaboulay  procedure  is  the  only  one  that  will  control 
the  situation.  It  can  be  employed  as  a  prophylactic 
measure  when  the  want  of  gastric  contractility  before 
operation  may  lead  one  to  fear  the  advent  of  this 
complication,  or  this  may  be  awaited,  and  when  the 
first  alarming  symptoms  develop  enteroanastomosis 
may  be  done  at  a  second  interference.  Before  resort- 
ing to  this  supplementary  interference  various  treat- 
ments can  be  essayed,  such  as  gastric  lavage,  which 
may  be  of  service  if  begun  at  the  onset  of  the  symp- 
toms, while  gastro-intestinal  stimulants  in  general, 
of  which  eserine  is  one  of  the  best,  should  be 
exhibited. 

Finally,  we  would  add  that  the  surest  means  of 
avoiding  this  complication  is  to  operate  before  the 
long  duration  of  the  process  has  already  involved 
gastric  contractility.  It  is  greatly  to  be  desired  that 
this  necessity  should  penetrate  the  minds  of  physicians, 
as  upon  them  rests  the  responsibility  of  advising 
surgical  measures. 


CHAPTER  III 

PULMONARY    COMPLICATIONS   AND   OPERATIVE    SHOCK 

THE  circumstances  favouring  the  development  of 
pulmonary  complications  arising  after  gastroenteros- 
tomy  and  other  procedures  are  multiple,  depending 
on  the  age  of  the  patient,  the  degree  of  cachexia,  the 
special  properties  of  the  blood,  the  decrease  of  the 
amplitude  of  the  respiratory  movements  after  laparo- 
tomy,  etc.  But  it  must  be  admitted  that  narcosis 
is  the  most  important  predisposing  cause  of  post- 
operative pneumonia  and  broncho-pneumonia.  More- 
over, it  is  generally  recognised  that  the  longer  the 
duration  of  narcosis,  the  more  pulmonary  com- 
plications are  to  be  feared. 

In  the  same  order  of  ideas,  collapses  and  operative 
shock  are  more  prone  to  occur  after  long  and 
laborious  interferences.  These  were  frequent  in  the 
early  days  of  gastroenterostomy  and  resections  of  the 
stomach,  because  in  1898,  out  of  a  total  of  580  cases 
of  gastroenterostomy,  Clumsky  found  fifty-four 
deaths  occurring  within  the  first  twenty-four  hours 
following  the  operation.  This  serious  complication 
is  to  be  especially  feared  when  the  patient  is  cachectic 
and  has  reached  an  advanced  degree  of  emaciation. 
This  state  of  general  weakness  is  principally  met  with 
in  cancer  cases,  it  is  true,  but  in  many  instances  of 
non-malignant  gastric  processes  the  patient  does  not 


46  SURGICAL  TREATMENT 

consult  the  surgeon  until  he  has  become  cachectic. 
This  being  the  case,  it  may  be  said  that  both  in  non- 
malignant  and  carcinomatous  gastric  processes  a  long 
interference,  requiring  a  protracted  narcosis,  should  be 
avoided.  The  operation,  whatever  the  procedure,  is 
to  be  conducted  with  all  rapidity  compatible  with 
thorough  surgery.  The  sutures  must  be  exactly  made, 
and  always  without  haste,  and  under  no  pretext 
should  an  attempt  be  made  to  economise  time  while 
this  is  being  done. 

The  problem  is,  therefore,  to  obtain  a  practical 
and  sure  procedure,  yet  with  a  minimum  amount  of 
suturing,  since  this  is  the  longest  part  of  any  gastro- 
intestinal technique,  and  this  subject  has  been  much 
discussed.  If  sutures  could  be  dispensed  with  alto- 
gether, the  technique  would  be  enormously  simplified ; 
and,  in  fact,  many  very  ingenious  procedures  have 
been  devised,  the  most  important  of  which  we  will 
recall. 

In  the  first  place,  as  an  historical  curiosity,  we 
would  say  that  in  1826  Denans,  of  Marseilles, 
invented  a  kind  of  anastomosis  button  that  he 
experimented  with  successfully  on  dogs,  but  it  can 
readily  be  conceived  that  at  this  epoch  no  great 
importance  was  attached  to  this  invention.  But  for 
all  that  Denans'  button  is  the  ancestor  of  Murphy  and 
Jaboulay's  contrivances. 

The  first  to  devise  and  employ  an  instrument  for 
rapidly  anastomosing  the  stomach  with  the  intestine 
was  Senn,  who  presented  his  anastomosis  button  to 
the  profession  in  1887.  After  him  several  surgeons 
proposed  similar  devices  with  an  attempt  to  use 


PULMONARY  COMPLICATIONS          47 

absorbable  material.  Thus  Littlewood,  Sachs  and 
Neuberg  essayed  decalcified  bone,  Dennis  catgut 
plates,  Brockow  a  cow's  dried  artery,  Hohenhauser 
cacao  butter  tubes,  while  Dawbron  and  Landerer 
employed  potatoes  and  Baracz  turnips  for  the  same 
purpose.  But,  before  them  all,  the  illustrious  French 
surgeon  Jean  Louis  Petit  was  in  the  habit  of  using 
the  dried  trachea  of  a  calf  inserted  into  the  lumen  of 
the  intestine,  over  which  he  sutured  the  wound  in  the 
gut,  as  far  back  as  1750. 

It  should  be  said  at  once  that  all  these  essays  were 
not  fortunate,  and  unabsorbable  buttons  were  taken 
up  again,  the  most  important  of  which  is  Murphy's 
instrument.  This  button,  remarkable  for  its  sim- 
plicity, as  well  as  for  security  in  the  fulfilment  of  its 
functions,  has  been  severely  criticised,  although  it 
remains  the  best  of  all  buttons  yet  devised. 

Murphy  published  his  procedure  in  1894,  after 
experimenting  with  his  button,  and  soon  the  instru- 
ment became  in  use  in  England  and  on  the  Continent. 
Some  surgeons  used  it  very  extensively,  while  others, 
on  the  contrary,  rejected  it  without  even  a  trial, 
while  Roux  gave  it  up  simply  because  the  first 
case  in  which  he  used  it  was  not  successful. 

Although  some  surgeons  immediately  decided  for 
or  against  the  instrument,  the  majority  did  not 
pronounce  an  opinion  one  way  or  another,  and  from 
this  hesitancy  there  were  published  innumerable 
papers  on  the  subject.  The  advantages  and  dis- 
advantages of  the  procedure  were  sharply  commented 
on,  but  finally  distinct  opinions  were  arrived  at.  It 
is  interesting  to  observe  how  the  results  obtained  by 


48  SURGICAL  TREATMENT 

various  operators  differ.  This,  in  our  opinion,  is  due 
to  two  causes.  The  first  is  the  manufacture  of  the 
button  itself,  which  must  be  extremely  careful  and 
varies  greatly  with  the  maker.  We  always  employ 
English  or  American  makes,  and  are  fearful  of  any 
German  manufacture,  which  is  invariably  poor  in 
quality  and  of  inferior  workmanship.  We  have  used 
the  Murphy  button  some  eighty  times  in  our  gastro- 
intestinal surgery,  and  the  only  fatal  case  was  one  in 
which  a  German  instrument  was  used,  which  came 
apart  after  the  abdomen  was  closed. 

The  second  cause  of  difference  in  results  is  the 
more  or  less  exactness  with  which  the  button  is 
placed.  The  anastomosis,  which  seems  so  simple, 
should  be  carried  out  with  as  much  care  as  suturing. 
This  point  was  brought  out  by  Murphy  himself. 

The  great  advantage  of  Murphy's  button  is  the 
time  saved,  but  the  partisans  of  this  procedure 
attribute  others  to  it,  particularly  better  function- 
ating of  the  gastro-intestinal  stoma.  Daneel  pub- 
lished the  following  statistics  in  this  regard  :  out  of 
a  total  of  547  posterior  gastroenterostomies  with 
suture,  fourteen  times  there  was  vomiting  of  bile, 
while  this  only  occurred  five  times  out  of  a  total  of 
548  von  Hacker's  operations  done  with  Murphy 
buttons.  It  is  to  be  noted  that  in  these  statistics 
the  operative  procedure  was  the  same,  since  the 
cases  were  operated  on  by  the  same  surgeon  or  his 
assistants. 

On  the  other  hand,  the  button  offers  some  dis- 
advantages or  even  some  dangers,  although  these 
are  often  exaggerated  by  writers  who  have  dealt 


PULMONARY   COMPLICATIONS          49 

with  this  subject.  The  following  are  the  reproaches 
usually  addressed  to  the  button  :  it  is  a  foreign  body 
introduced  into  the  gastro-intestinal  canal  and 
therefore  must  be  eliminated,  and  this  elimination 
may  not  take  place  without  causing  serious  accidents. 
As  far  back  as  1894  Chaput  undertook  some  experi- 
mental work  in  this  regard,  and  noted  that  in  the 
cadaver  buttons  of  sufficient  diameter  to  assure 
good  functionating  of  the  stoma  passed  down  the 
intestine,  causing  marked  compression  of  the  walls,  in 
ten  out  of  twelve  cases,  while  in  two  the  button  could 
not  pass  at  all.  In  spite  of  these  unfavourable  experi- 
ments, the  button  is  usually  eliminated  quite  easily, 
and  rarely  gives  rise  to  post-operative  disturbances. 
When  the  button  is  not  eliminated  it  is  because  it 
drops  into  the  gastric  cavity,  where  it  sojourns 
without  giving  rise  to  any  symptoms.  This  likewise 
applies  to  its  sojourn  in  the  duodenum,  but,  on  the 
other  hand,  if  it  remains  wedged  in  the  lower  portion 
of  the  intestine  it  may  give  rise  to  some  symptoms, 
particularly  those  of  incomplete  occlusion  with  pain, 
usually  confined  to  the  right  iliac  fossa.  Severer 
symptoms  than  these  are  very  rare,  but  complete 
occlusion,  requiring  an  operation  for  its  relief,  has 
been  known  to  occur,  but  in  those  cases  where  no 
adhesion  formed  an  evident  obstacle  to  its  passage  no 
explanation  could  be  found  of  the  arrest  of  the 
button.  Autopsies  showed  that  the  lumen  of  the 
intestine  was  amply  sufficient  to  allow  the  button 
to  pass.  Those  writers  who  have  dealt  with  this 
subject  have  adopted  the  hypothesis  of  an  intestinal 
spasm  taking  place  on  the  button,  as  occurs  in  cases 

S.T.  E 


50  SURGICAL  TREATMENT 

of  ileus  from  biliary  calculi  during  elimination  through 
the  intestine. 

The  button  has  also  been  accused  of  producing 
perforation  at  the  spot  of  the  anastomosis,  and,  there- 
fore, does  not  give  the  same  security  as  suture. 
Dehiscence  is  due  to  a  badly  constructed  button,  as 
we  have  already  pointed  out,  to  insufficient  blood 
supply  of  the  peritoneum  from  too  tight  compression, 
or  to  too  strong  traction  on  the  anastomosis.  From 
this  fact  it  is  clear  that  anterior  gastroenterostomy 
lends  itself  less  to  the  use  of  Murphy's  button  than 
does  von  Hacker's  procedure.  But  if  the  results  of 
different  surgeons  be  examined,  and  if  cases  of 
insufficient  suturing  and  cases  of  perforation  when 
the  button  was  used  be  compared,  it  will  be  seen  that 
the  figures  are  almost  equal.  Thus  among  the  more 
important  statistics  we  find  : — 

Daneel :    380  cases  with  the  Murphy  button 
without  dehiscence. 

Peurer  :    117  anterior  gastroenterostomies  with 

four  dehiscences. 
With  suturing  the  following  figures  are  found  :— 

Garr6  :  55  cases  with  sutures,  three  perforations. 

Von  Hacker  :  22  cases  with  suture,  one  perfora- 
tion. 

Kroenlein  :  74  cases  with  suture,  no  perforation. 

Korte  :  88  cases  with  suturing,  no  perforation. 
If  the  button  is  well  made,  carefully  placed,  and 
only  employed  in  posterior  gastroenterostomy,  there 
will  be  no  greater  danger  from  dehiscence  or  perfora- 
tion than  when  sutures  are  used.  In  reality  what  are 
the  cases  in  which  dehiscences  occur  if  they  are  not 


PULMONARY  COMPLICATIONS          51 

those  in  which  the  tissues  lack  resistance  from  ill 
nourishment,  and  usually  in  profoundly  cachectic 
patients?  The  perforation  results  less  from  the 
procedure  employed  than  from  circumstances  foreign 
to  the  technique. 

Although  Petersen  is  a  partisan  of  Murphy's  button, 
he  has  called  attention  to  the  danger  of  giving  a 
bad  direction  to  the  efferent  branch,  thus  producing 
a  bend,  when  this  instrument  is  used.  It  is  enough 
to  be  warned  of  this  possibility  in  order  to  avoid  it, 
but  this  surgeon  has  met  with  three  cases  of  bad 
functionating  of  the  stoma  from  a  too  pronounced 
rotation  of  the  intestine  on  the  stomach,  occurring 
at  the  time  when  the  button  was  tightened  down. 
He  is,  so  far  as  we  are  aware,  the  only  writer  who  has 
mentioned  this  danger. 

Several  writers  have  feared  that  the  stoma  might 
contract  after  elimination  of  the  button,  thus  pro- 
ducing remote  functional  disturbances.  Daneel 
mentions  five  cases  which  required  a  secondary  plastic 
operation  on  the  anastomosis  from  contraction  of  the 
stoma ;  all  recovered.  These  post-operative  contrac- 
tions occur  frequently  with  sutures.  It  is  a  complica- 
tion occurring  in  one  procedure  as  well  as  another, 
but,  for  want  of  statistics  on  the  subject,  the  com- 
parative results  in  this  regard  are  wanting. 

Consequently,  if  we  sum  up  the  advantages  and 
disadvantages  of  the  Murphy  button,  it  may  be  said 
that,  firstly,  about  ten  minutes  will  be  gained  in  the 
execution  of  the  operation,  the  technique  is  simplified, 
and  the  functions  of  the  stoma  are  better  carried  out, 
at  least  during  the  first  days  following  the  interference. 

E  2 


52  SURGICAL  TREATMENT 

Secondly,  the  danger  of  intestinal  occlusion — a  very 
rare  complication — and  perforation  or  dehiscenee  of 
the  anastomosis  is  not  more  frequent  than  when 
sutures  have  been  used. 

As  to  the  indications  for  the  use  of  Murphy's 
button,  we  would  venture  to  suggest  the  following  :— 

(1)  In   cases   of   posterior   gastroenterostomy   in 
cachectic  patients  or  those  in  a  state  of  advanced 
emaciation ; 

(2)  In  resection  according  to  Billroth's  procedure 
II.,  on  account  of  the  reduction  in  the  duration  of  an 
already  long  procedure. 

Suture  is  to  be  preferred — 

(1)  When  the  duration  of  the  operation  is  of  small 
importance ; 

(2)  In  any  technique  of  resection  excepting  in 
Billroth's  procedure  II. ; 

(3)  In  procedures  of  gastroenterostomy,  especially 
anterior  gastroenterostomy,  which  cause  dragging  on 
the  anastomosis. 

Therefore  Murphy's  button  offers  great  advan- 
tages, but  only  in  well- denned  cases ;  and,  excepting 
in  these  special  indications,  suture  is  unquestionably 
to  be  preferred.  Among  those  surgeons  who  main- 
tain a  similar  opinion  may  be  mentioned  Mayo- 
Robson,  Moynihan,  Hartmann  and  Pauchet,  while 
others,  like  Steinheil,  Petersen  and  Daneel,  all  three 
Czerny's  former  assistants,  recommend  the  button 
as  a  method  of  choice. 

We  have  only  referred  to  Murphy's  button  in  our 
discussion.  We  have  employed  both  Jaboulay's  and 
Chaput's  anastomosis  buttons  as  well  and  obtained 


PULMONARY  COMPLICATIONS          53 

perfect  results  with  each  instrument.  Jaboulay's 
button  is  a  more  delicate  instrument,  and  requires 
thorough  verification  of  its  mechanism  before  it 
is  used.  Chaput's  button,  of  which  there  are 
several  sizes,  is  the  simplest  of  all,  but  we  do  not 
know  that  it  is  being  employed,  to  any  extent  at 
least,  at  the  present  time.  Of  the  other  buttons  on 
the  market  we  have  had  no  personal  experience. 


CHAPTER  IV 

THE    RESECTIONS 

IN  speaking  of  resections,  and  of  pylorectomy  in 
particular,  in  cases  of  non-malignant  affections  of  the 
stomach,  Monprofit  said,  in  1905,  that  "  in  the 
majority  of  cases  operation  was  undertaken  as  a 
result  of  erroneous  diagnosis.  A  malignant  neoplasm 
was  suspected  whose  removal  was  urgent,  and  the 
surgeon  found  that  he  had  been  mistaken.  But  since 
these  mistakes  are  unavoidable  in  practice,  and  as 
they  will  be  committed  for  some  time  to  come,  it  is 
proper  to  mention  this  interference  (resection)  and 
even  to  study  it  with  care,  although  from  now  on,  in 
many  cases,  it  will  be  replaced  by  simple  gastro- 
enterostomy." 

Such  was  the  generally  recognised  opinion  at  that 
epoch,  but  since  then,  and  especially  of  late,  surgeons 
tend  more  and  more  to  deal  with  gastric  ulcer  by 
more  radical  procedures.  We  shall  attempt  to  show 
the  cause  for  this  evolution.  It  must  be  admitted 
that  the  progress  made  in  technique  has  been  the 
means  of  greatly  extending  the  indications  for  pro- 
cedures considered  dangerous  only  a  few  years  ago. 

Pylorectomy 

The  first  pylorectomies  for  malignant  disease  were 
performed  by  Czerny  (1878)  and  Pean  (1879).  In 


THE  RESECTIONS  55 

1891  Rydygier  did  the  operation  in  a  case  of  non- 
malignant  stenosis  of  the  pylorus.  In  the  following 
year  von  Vileeg  did  the  same,  and  after  this  the  list 
of  these  operations  became  long. 

In  1886  Salzmann  published  an  interesting  paper 
based  on  a  study  of  seventy-six  pylorectomies.  In 
this  number  he  included  all  the  cases  that  had  been 
recorded  up  to  that  year  and  gave  some  interesting 
information  in  regard  to  the  early  beginning  of  this 
operation.  Of  the  seventy-six  cases  referred  to  in  the 
paper  we  only  find  seven  of  non-malignant  stenosis, 
with  four  post-operative  deaths. 

The  operative  mortality,  which  in  1880  was 
100  per  cent. — including  cases  of  cancer — quickly 
dropped  to  64  per  cent,  in  1883  and  to  20  per  cent. 
in  1885.  Billroth  was  the  chief  promoter  of  this 
operation,  since  out  of  the  seventy-six  cases  he 
himself  operated  on  sixteen,  and  with  his  assistants 
Mikulicz,  Czerny,  Gussenbauer  and  Woelfler,  he 
reached  a  total  of  twenty-six. 

The  then  still  high  operative  death-rate  hardly 
encouraged  surgeons  to  adopt  this  procedure  in 
non-malignant  cases,  and  some  preferred  Loretta's 
pyloric  divulsion  even  to  gastroenterostomy,  which 
still  had  a  high  mortality. 

During  these  few  years  the  procedures  of  resection 
increased  in  number,  while  the  technical  details  were 
developed.  Displeased  with  his  first  procedure, 
Billroth  described  his  second  procedure  in  1885. 
Shortly  afterwards  Kocher  presented  his  operation 
(1887).  Thus  the  operative  results  improved,  but 
at  the  same  time  gastroenterostomy  became  less  and 


56  SURGICAL  TREATMENT 

less  dangerous,  while  most  surgeons  resorted  to  it  in 
duly  recognised  cases  of  non-malignant  stenosis.  It 
was  at  this  time  (1887)  that  Czerny  performed  the 
first  partial  resection  of  the  stomach  without 
involving  the  continuity  of  the  gastro- intestinal  tract. 

Partial  resection  was  hardly,  if  ever,  done  in  the 
following  years.  Gastroenterostomy  sufficed  in  the 
opinion  of  all  surgeons,  but  little  by  little,  from  the 
influence  exerted  by  Brenner  and  Lorenz,  a  change 
took  place,  and  many  surgeons  thought  that  resection 
was  the  only  proper  treatment  for  ulcer  of  the 
stomach. 

Several  surgeons  had  had  bad  results  following 
gastroenterostomy.  They  particularly  feared  cancer 
graft,  secondary  haemorrhage  or  perforation,  all 
which  complications  had  occurred  in  spite  of  this 
operation.  One  of  the  chief  arguments  in  favour 
of  resection  was  the  one  advanced  by  Brenner  in 
1903,  namely  the  penetration  of  the  ulcer  into  an 
adjacent  organ  and  callous  degeneration  of  this 
lesion.  Some  time  before  Brenner  several  surgeons 
had  resected  ulcers  which  had  penetrated  the 
parenchyma  of  the  liver  or  pancreas,  while  Korte  had 
even  excised  a  portion  of  the  anterior  abdominal 
wall  comprising  inflammatory  callous  masses  arising 
from  a  perforating  gastric  ulcer.  The  callosities 
forming  an  inflammatory  tumour  were  considered, 
and  rightly  so,  as  an  indication  for  resection  on 
account  of  the  pain  caused  by  the  adhesions  present. 

While  admitting  without  question  the  curative 
effect  of  gastroenterostomy  on  simple  ulcer,  surgeons 
considered  that  this  procedure  was  devoid  of  any 


THE  RESECTIONS  57 

influence  over  the  callous  tissues  infiltrating  the 
adjacent  viscera.  Regardless  of  the  data  brought 
forward  by  the  partisans  of  resection,  the  majority 
of  surgeons  remained  faithful  to  gastroenterostomy 
up  to  1910.  Of  course  some  resections  were  done, 
but  only  infrequently. 

In  1904  Brenner  retracted  his  assertions  put 
forward  the  year  before  after  he  had  had  the  oppor- 
tunity of  observing  two  cases  of  inflammatory 
tumours  which  disappeared  following  gastroenteros- 
tomy. He  became  less  categorical  and  only  proposed 
resection  in  cases  in  which  the  lesion  was  limited  in 
extent  and  the  adhesions  easy  to  break  down.  This 
change  of  opinion  on  the  part  of  a  convinced  partisan 
of  radical  procedures  had  its  effect,  and  resections 
were  afterwards  less  frequently  done. 

During  the  last  decade  or  more  there  has  been  a 
renewed  tendency  in  France  in  favour  of  resection. 
Thus  Brechot,  Fayasse,  Gauthier  and  Rivier  some 
years  ago  concluded  in  favour  of  resection  of  the 
pylorus,  annular  resection  of  the  stomach  or  excision 
of  the  ulcer,  and  discarded  gastroenterostomy,  which 
they  regarded  as  offering  serious  disadvantages. 
This  tendency  has  become  more  marked  of  late,  and 
in  some  quarters  at  present  the  partisans  of  gastro- 
enterostomy are  looked  upon  as  being  behind  the 
times.  In  our  opinion  there  is  some  exaggeration 
in  this  disparagement  of  gastroenterostomy  ;  and 
although  this  procedure  cannot  cure  all  cases  of 
gastric  ulcer,  we  maintain  that  it  gives  excellent 
results  in  the  vast  majority  of  cases. 

As  to  'the  technique  of  resections,  we  will  simply 


58  SURGICAL  TREATMENT 

mention  the  various  procedures  employed  at  the 
present  time.  We  will  first  divide  resections  into 
two  classes,  namely  : — 

(1)  Transversal  gastrectomies. 

(2)  Lateral  gastrectomies. 

Among  the  first  we  include  pylorectomy,  which  is 
most  frequently  performed,  and  annular  gastrectomy. 

As  to  total  gastrectomy,  we  know  of  no  case  in 
which  this  has  been  done  for  non-malignant  lesions. 
Monprofit  mentions  two  cases  of  complete  removal 
of  the  stomach  for  plastic  linitis,  but  as  the  etiology 
of  this  morbid  process  is  not  as  yet  clear,  and  as  many 
writers  regard  it  as  a  special  form  of  cancer,  we  shall 
not  discuss  the  subject. 

Transversal  Gastrectomy. — The  difficulty  of  this 
procedure  mainly  resides  in  the  approximation  and 
suture  of  the  divided  parts.  In  fact,  in  annular 
gastrectomy  and  especially  in  pylorectomy,  the 
diseased  portion  having  been  excised,  the  surgeon 
finds  himself  face  to  face  with  two  unequal  surfaces 
whose  coaptation  is  particularly  delicate.  For  this 
reason  various  types  of  procedure  have  been 
successively  proposed. 

Billroth's  first  procedure  was  at  first  sight 
regarded  as  the  most  rational,  namely,  the  termino- 
terminal  anastomosis  of  the  two  divided  portions  of 
the  stomach  with  a  preliminary  partial  closure  of  the 
gastric  portion  in  such  a  way  as  to  leave  an  opening 
equal  to  that  of  the  pyloric  end.  But  the  results 
were  more  than  mediocre.  The  majority  of  patients 
died  from  peritonitis  due  to  perforation  or  dehiscence 
of  the  suture  line.  The  point  at  which  the  lateral 


THE  RESECTIONS  59 

suture  of  the  stomach  united  with  the  gastro- 
duodenal  circular  suture  was  the  weak  spot ;  more- 
over, the  numerous  sutures  inserted  at  this  spot 
interfered  with  the  blood  supply  of  the  tissues,  while 
the  dragging  on  the  rather  immovable  duodenum 
contributed  to  the  separation  of  the  latter  organ  with 
the  stomach. 

In  his  paper  which  gives  the  statistics  of  the 
resections  performed  by  Billroth  and  his  assistants 
up  to  the  year  1899,  von  Eiselsberg  shows  that,  out 
of  ten  autopsies  following  resection,  in  seven  there 
was  peritonitis  from  perforation  in  the  line  of  sutures. 
Of  eight  cases  of  resection  for  non-malignant  stenoses 
which  most  concern  us,  there  were  four  deaths  from 
peritonitis  due  to  this  cause. 

In  the  first  series  of  resections,  comprising  eighteen 
cases  operated  on  by  Billroth,  there  were  ten  deaths, 
nine  of  which  were  due  to  perforation.  All  these 
cases,  with  one  exception,  had  been  operated  on  by 
Billroth's  first  procedure.  In  1888  he  developed  the 
principle  of  his  second  technique  for  a  case  of  exten- 
sive cancer  of  the  pyloric  portion  of  the  stomach. 
The  duodenal  portion  of  the  resected  stomach  was 
completely  closed,  and  the  jejunum  anastomosed 
with  the  lower  part  of  the  gastric  section,  the  upper 
portion  of  this  section  having  been  closed  by  Lem- 
bert's  sutures.  This  procedure  was  also  employed  by 
Doyen  and  Rydygier. 

It  was  only  at  a  later  date  that  Billroth  understood 
that  the  defect  of  his  method  was  not  so  much  due 
to  the  limited  mobility  of  the  duodenum  as  it  was  to 
the  insecurity  of  the  union  at  the  same  point  of  the 


60  SURGICAL  TREATMENT 

circular  sutures  of  the  anastomosis  and  the  rectilinear 
sutures  of  the  closed  portion  of  the  gastric  section. 
He  then  decided  to  make  two  terminal  sutures  on  the 
stomach  and  duodenum,  and  to  reconstruct  the 
intestinal  continuity  by  an  independent  anastomosis. 

Such  is  the  true  procedure  II.  of  Billroth.  He  like- 
wise employed  Woelfler's  or  von  Hacker's  gastro- 
enterostomy,  while  at  a  later  date  other  surgeons 
used  Roux's  Y-shaped  anastomosis.  The  results 
quickly  improved,  and  in  several  statistics  it  will  be 
found  that  the  mortality  was  hardly  higher  for 
resection  than  for  simple  gastroenterostomy. 

The  great  disadvantage  of  this  procedure  of 
pylorectomy  is  the  time  consumed  when  it  is  carefully 
carried  out,  but  as  it  is  composed  of  two  very  distinct 
steps,  it  was  inevitable  that  at  length  the  two  steps 
should  be  divided  into  two  separate  operations. 
Thoulke,  in  1891,  was  the  first  to  propose  the  two-step 
operation,  in  serious  cases  in  which  a  prolonged 
narcosis  was  to  be  avoided.  Gastroenterostomy  was 
first  done  in  order  to  improve  the  general  condition  of 
the  patient,  while  pylorectomy  was  performed  some 
weeks  later.  Although  this  procedure  was  par- 
ticularly indicated  in  cancer  cases,  it  was  employed 
everywhere  for  non-malignant  pyloric  stenosis  as 
well. 

Billroth's  second  procedure  in  two  operations  is 
the  one  that  is  much  employed  at  present,  because  it 
offers  the  unquestionable  advantage  of  being  adapt- 
able to  almost  all  cases.  If  the  tumour  is  very  exten- 
sive or,  on  the  other  hand,  very  small,  whether  the 
duodenum  be  movable  or  not,  the  operation  can  be 


THE  RESECTIONS  61 

carried  out  under  all  circumstances.  The  same 
cannot  be  said  of  Kocher's  latero-terminal  pylo- 
rectomy. 

In  1887  Kocher  proposed  a  procedure  of  pylo- 
rectomy  just  the  inverse  to  Rydygier's  procedure.  He 
preferred  to  completely  close  the  gastric  incision  and 
then  anastomose  the  duodenum  with  the  anterior  or 
posterior  gastric  wall.  This  technique,  which  unfortu- 
nately is  far  from  being  adaptable  to  all  cases, 
presents  great  advantages.  In  fact,  the  gastric 
stoma  being  placed  near  the  pylorus  assures  good 
evacuation  of  the  stomach,  the  peristaltic  waves 
pushing  the  gastric  contents  exactly  in  this  direction. 
Moreover,  this  procedure  does  not  exclude,  as  does 
simple  gastroenterostomy,  the  duodenum,  which,  if 
not  the  seat  of  secretion,  is  at  least  the  seat  of  reflexes 
which  exercise  an  important  action  over  the  act  of 
digestion.  To  these  physiological  and  theoretical 
advantages  may  be  opposed  the  fact  that  this  pro- 
cedure loses  the  benefit  of  automatic  neutralisation 
of  the  gastric  juice  by  the  addition  of  the  pancreatic 
and  biliary  secretions.  This  is  an  important  point 
to  which  we  shall  refer  further  on. 

As  we  have  said,  this  technique,  which  is  excellent 
in  certain  circumstances,  can  rarely  be  employed 
with  all  desirable  security.  This  type  of  pylorectomy 
has  been  unsuccessful  at  the  hands  of  several  surgeons, 
the  result  of  dehiscence  of  the  sutures,  so  that 
peritonitis  from  perforation  took  place,  as  in  Billroth's 
first  procedure.  These  surgeons  undoubtedly  often 
owed  their  unsuccessful  results  to  the  confidence  that 
they  placed  in  this  technique,  which  had  been  warmly 


62  SURGICAL  TREATMENT 

lauded.  They  forgot  that  the  duodenum  is  a  fixed 
organ  which  can  be  hardly  at  all  displaced,  and  in 
which  sutures  offer  no  security  whatsoever. 

Moreover,  for  those  surgeons  who  employ  Murphy's 
button  or  some  similar  device  the  simple  gastro- 
enterostomy  in  Billroth's  second  procedure  is  cer- 
tainly preferable.  In  an  interference  requiring  so 
long  a  time  as  pylorectomy  it  is  by  no  means 
indifferent  to  be  able  to  curtail  it  by  a  few  minutes, 
and  it  is  in  these  circumstances  that  a  well-applied 
button  can  render  real  service.  Now  it  is  dangerous 
to  use  the  button  in  Kocher's  gastro-duodenal 
anastomosis,  and  several  surgeons  have  tried  it 
with  numerous  disastrous  results.  It  was  soon  dis- 
covered that  the  button  was  seated  exactly  in  front 
of  the  spine  and,  therefore,  compressed  the  intestinal 
wall  against  this  resistant  bony  plane,  which  resulted 
in  localised  necrosis  followed  by  perforation  and 
general  peritonitis. 

Nevertheless  at  present  the  two  procedures  of 
pylorectomy  the  most  in  favour  are  unquestionably  :— 

(1)  Billroth's  second  procedure,  applicable  to  all 
cases. 

(2)  Kocher's  procedure,  which  offers  great  advan- 
tages, but  can  only  be  employed  in  a  restricted 
number   of   cases,   especially  when   the   duodenum 
can  be  easily  mobilised. 

During  the  past  few  years  surgeons  are  more  and 
more  reverting  to  a  procedure  which,  in  the  early 
days  of  pylorectomy,  had  been  proposed  by  Kroen- 
lein  and  Rydygier.  This  procedure  consists  of  closing 
the  duodenum  and  then  implanting  the  lower  portion 


THE  RESECTIONS  63 

of  the  gastric  section  into  the  first  portion  of  the 
jejunum.  Otherwise  put,  it  is  a  termino-lateral 
anastomosis.  It  has  been  advocated  by  the  Vienna 
school,  especially  by  Polya,  who,  with  others,  has  made 
some  technical  changes.  For  some  surgeons  it  is  the 
method  of  choice,  some  implanting  the  entire  gastric 
section,  others  partially  closing  it  before  implanting 
the  rest. 

This  procedure  has  the  advantage  of  permitting 
more  extensive  resection.  There  will  always  be 
sufficient  material  in  the  remaining  portion  of  the 
stomach  for  suturing,  while  in  extensive  resections 
by  Billroth's  second  procedure  there  is  often  difficulty 
in  placing  the  anastomosis,  and  this  is  still  more 
difficult  in  Billroth's  first  procedure.  It  also  has  the 
advantage  of  saving  time,  since  one  plane  of  sutures 
is  done  away  with. 

The  technique  is  simple,  and  offers  all  requisite 
security.  It  assures  perfect  functions  of  the  stoma 
as  well.  However,  Moynihan  fears  bending  of  the 
jejunum,  which  is  possible  to  occur  at  the  upper  part 
of  the  anastomosis,  and,  in  order  to  avoid  this  risk,  he 
performs  a  Y-shaped  procedure ;  and,  instead  of 
implanting  the  jejunum  into  the  stomach,  he  closes 
the  vertical  branch  of  the  Y  and  implants  it  laterally 
in  the  gastric  section. 

This  operation,  which  we  have  recommended, 
seems  uselessly  complicated,  the  results  of  the 
ordinary  technique  having  been  perfectly  satisfac- 
tory. Moreover,  we  believe  that  Y-shaped  anasto- 
moses are  hardly  to  be  recommended  for  reasons  that 
we  shall  give  further  on. 


64  SUBGICAL  TEEATMENT 

Annular  Gastrectomy 

Annular  gastrectomy  consists  of  excising  an 
annular  portion  of  the  middle  of  the  stomach  with 
termino-terminal  union  of  the  two  resulting  gastric 
sections.  This  operation  preserves  the  integrity  of 
the  gastric  physiology  in  that  the  sphincter  is 
respected,  and  this  is  the  chief  feature  differentiating 
it  from  pylorectomy.  First  performed  by  Bassolo, 
this  procedure  has  been  especially  studied  by  Bieder, 
and  more  recently  by  Leriche.  Both  these  writers 
strongly  recommend  it,  and  consider  it  to  be  the 
method  of  choice  in  the  treatment  of  bilocular 
stomach  as  well  as  ulcer  of  the  lesser  curvature. 

In  spite  of  these  really  serious  papers  and  the  good 
results  obtained  by  the  writers,  their  example  has 
not  been  followed  by  many.  The  indications  for 
this  operation  have  not  been  developed  to  any  great 
extent,  and  usually  simple  gastroenterostomy  is 
preferred.  When  speaking  of  the  indications  for 
each  procedure  in  the  various  non-malignant  affec- 
tions of  the  stomach,  we  shall  attempt  to  show  that 
alone  biloculation  of  the  stomach  from  cicatricial 
contraction  is  suitable  for  annular  gastrectomy. 

As  to  the  technique  of  the  operation,  it  is  self- 
explanatory,  and  although  the  principle  is  invariably 
the  same,  the  details  depending  upon  the  anatomical 
circumstances  vary  enormously.  The  operative  diffi- 
culty essentially  depends  upon  the  extent  of  the  adhe- 
sions, so  that  technical  rules  cannot  be  formulated. 

Bieder  and  Leriche  mention  the  following  points, 
which  are  deserving  of  attention  :— 

(1)  The  resection  should  be  sufficiently  extensive 


THE  EESECTIONS  65 

to  include  all  diseased  tissue,  so  that  the  union  between 
the  cardiac  and  pyloric  sections  will  be  made  in 
healthy  tissue. 

(2)  The  surfaces  of  section  of  the  two  portions 
must  be  equal,  as  it  is  all-important  to  obtain  exact 
coaptation  and  to  avoid  any  folds  in  the  suture  line. 
It  is  essential  to  attend  to  this  detail  at  the  onset  of 
the  operation,  and  not  to  overlook  it  when  excising 
the  parts.  A  more  or  less  oblique  or  perpendicular 
division  may  increase  the  length  of  the  section  to 
twice  the  necessary  extent.  The  line  of  incision  can 
thus  be  calculated,  so  that  at  the  end  of  the  operation 
the  length  of  each  section  will  be  equal. 

If  these  details  are  attended  to  and  if  breaking 
down  of  the  adhesions  does  not  in  itself  present 
technical  difficulties,  the  operation  will  be  easy  and 
may  give  excellent  immediate  results.  But  the 
remote  results  are,  unfortunately,  less  brilliant. 
Cicatricial  contraction  frequently  recurs  in  the  suture 
line,  producing  secondary  biloculation.  Moreover, 
division  of  the  intragastric  nerve  fibres  and  those 
of  the  lesser  curvature  is  prone  to  provoke  disturb- 
ances of  motility  of  the  organ.  Hence  the  opera- 
tion is  rarely  resorted  to,  and  this  all  the  more  so 
because  the  necessary  anatomical  conditions  for  its 
performance  are  not  often  found.  Now  these  anato- 
mical conditions — extension  of  the  lesion  and  adhe- 
sions to  the  liver  or  pancreas — have  a  too  considerable 
importance  not  to  be  taken  into  serious  consideration. 

Lateral  gastrectomies  need  not  detain  us,  because 
they  are  always  performed  on  the  spur  of  the  moment, 
so  that  the  technique  will  vary  with  each  case. 


S.T. 


66  SURGICAL  TREATMENT 

Alone,  the  procedure  recently  introduced  by  Balfour 
merits  some  consideration  here.  This  is  cautery 
excision  of  the  ulcer,  and  was  first  described  by 
Balfour  in  1914.  In  1918  this  surgeon  refers  to 
214  cases  at  the  Mayo  clinic  in  which  it  was  used. 
The  first  group  in  which  it  was  applied  comprised 
ulcers  of  the  lesser  curvature  so  high-seated  or  so 
extensively  indurated  as  to  make  excision  with  the 
knife  difficult.  In  the  circumstances  it  was  decided 
to  destroy  the  crater  of  the  ulcer,  as  well  as  to 
sterilise  the  infected  area  by  heat.  The  results  have 
been  very  satisfactory. 

The  procedure  is  not  applicable  to  ulcers  which 
have  undergone  malignant  transformation,  unless  the 
lesion  cannot  be  excised  because  of  its  size,  site  or 
fixation,  and  the  procedure  should  only  be  attempted 
when  the  stomach  can  be  sufficiently  mobilised  to 
ensure  safe  exposure.  In  gastric  ulcer  the  value  of 
the  procedure  seems  to  largely  depend  on  heat  and 
perforation.  The  sterilising  action  of  heat  is  too  well 
known  to  require  comment,  while  complete  perfora- 
tion by  the  cautery  point  through  the  centre  of  the 
crater  is  essential  because  of  the  clinical  fact  that 
spontaneous  complete  perforation  of  gastric  ulcer  is 
quite  likely  to  be  followed  by  both  cure  of  the  ulcer 
and  recovery  of  the  patient  when  he  survives. 

The  great  advantage  of  cautery  excision  is  its 
application  on  the  lesser  curvature,  and  Balfour  bears 
out  our  statement  that  excision  of  a  segment  of  the 
lesser  curvature  definitely  impairs  motility  of  the 
stomach,  as  we  pointed  out  in  regard  to  annular 
resection. 


THE  RESECTIONS  67 

The  actual  effect  of  the  cautery  may  be  studied 
from  four  view-points,  namely,  experimental,  clinical, 
operative  mortality  and  remote  results.  Mann's 
original  experiments  to  determine  the  healing  power 
of  the  stomach  after  an  opening  had  been  made  by 
the  cautery  and  closed  by  suture  showed  conclusively 
that  rapid  and  firm  healing  always  took  place,  even 
when  closure  of  the  cautery  opening  was  more  or  less 
imperfect.  The  experiments  carried  out  by  Scudder 
and  Harvey  confirmed  this. 

The  low  operative  risk  of  cautery  excision  com- 
bined with  gastroenterostomy  is  shown  by  the  fact 
that  in  the  186  cases  in  which  this  was  the  major 
operation  there  were  only  two  deaths,  one  from 
pulmonary  embolus  on  the  eighth  day,  the  other  on 
the  twentieth  day  from  pneumonia.  In  knife  exci- 
sion combined  with  gasteroenterostomy  there  were 
three  deaths  out  of  eighty -nine  cases.  The  remote 
results  are,  on  the  whole,  fairly  good.  Balfour 
mentions  the  highly  important  fact  that  there  has 
not  been  a  single  recurrence  of  hsemorrhage  following 
the  cautery  operation.  From  the  technical  stand- 
point the  cautery  accomplishes  much  in  a  simple  way 
which  is  not  true  of  the  knife.  Knife  excision, 
necessitating  as  it  does  the  complete  removal  of  the 
callous  area,  is  unsatisfactory  in  many  cases  even 
when  anatomical  conditions  permit  its  execution. 

Operative    Indications 

It  can  be  said  that  surgical  treatment  has  been 
attempted  in  the  majority  of  chronic  gastric  affec- 

r  2 


68  SUKGICAL  TREATMENT 

tions,  and  at  one  time,  at  least,  operations  were 
performed  recklessly,  with  disastrous  results,  which 
ended  in  much  discredit  being  cast  upon  this  branch 
of  surgery. 

It  is  only  within  the  past  fifteen  years  that  the 
operative  indications  have  been  determined ;  and,  with 
the  exception  of  some  very  personal  difference  of 
opinion,  a  line  of  conduct  can  be  reached  which  will 
be  accepted  by  most  internists  and  surgeons.  The 
physiology,  pathology  and  pathogenesis  of  gastric 
processes  are  better  understood,  so  that  correct 
diagnoses  can  now  be  made. 

Finally,  study  of  the  remote  functional  results  has 
shown  the  intimate  action  of  operations  on  gastric 
physiology,  and  the  data  obtained  revealed  the  reason 
for  the  bad  results  accruing  in  many  cases.  It  was 
found  that  surgical  treatment  should  be  directed  to 
the  factors  engendering  the  lesion  rather  than  to  the 
lesion  itself.  Hence  were  developed  the  indications 
of  operations  having  an  indirect  action,  and  which  are 
at  the  present  time  perfectly  justified,  as,  for  example, 
gastroenterostomy  in  simple  gastric  ulcer. 

Therefore  one  should  not  speak  of  the  indications 
of  operative  treatment  in  general,  but,  on  the  con- 
trary, these  indications  should  be  studied  separately 
in  each  gastric  affection,  following  a  classification 
not  only  based  upon  the  principal  symptoms  of  the 
affection,  but,  above  all,  on  the  pathogenesis. 

Lastly,  the  various  operative  procedures  may  have 
very  different  effects  on  the  gastric  physiology,  there- 
fore on  the  lesions  considered  in  this  volume.  We 
shall  consequently  attempt  to  bring  into  relief  in 


THE  RESECTIONS  69 

each  affection  the  intimate  action  of  the  various 
surgical  procedures  and  then  from  this  study  select 
the  most  logical  and  surest  procedure  for  each 
morbid  process  considered.  Hence  in  each  affection 
we  shall  consider — (1)  the  causes,  (2)  the  operations 
that  have  been  employed  and  the  results  obtained, 
and  (3)  the  intimate  action  of  these  operations ;  and 
from  this  examination  we  shall  endeavour  not  only  to 
clear  up  the  operative  indications  in  general,  but  also 
the  special  indications  of  the  principal  procedures 
currently  employed.  First,  coming  to  the  principal 
indications  now  generally  admitted,  we  will  succes- 
sively study  the  indications  for  operative  treatment 
in  the  following  order  :— 

(1)  Stenosis,  from  ulcer  in  activity,  from  cicatrised 
ulcer,  from  burns  with  caustic,  congenital,  from  bands 
and  adhesions. 

(2)  Ulcer,  which  is  divided  into  distinct  classes,  the 
indications  being  different  in  simple,  haemorrhagic, 
perforating  or  painful  ulcer. 

(3)  Dyspepsia,  from    secretory,  neuromotor    and 
spasmodic  disturbances. 

(4)  Gastric  Dystopia. 

(5)  Idiopathic  Dilatation. 

(6)  Tuberculosis  and  Syphilis  of  the  Stomach. 

(7)  Traumata. 

(8)  Foreign  Bodies. 


CHAPTER  V 

THE    STENOSES 

GASTRIC  stenoses,  usually  of  the  pylorus,  but  occa- 
sionally mediogastric,  constitute  the  indication  for 
operation,  the  oldest  in  date  and  the  least  discussed. 
They  are  likewise  the  most  frequent  cause  for  surgical 
interference,  and  also  give  the  surest  results. 

Stenosis  has  many  factors ;  and  although  in  the 
majority  of  cases  it  is  produced  by  some  purely 
gastric  morbid  process,  it  can  also  be  the  consequence 
of  inflammatory  lesions  primarily  involving  adjacent 
viscera.  The  various  stenoses  met  with  in  practice 
are  very  unlike  each  other  not  only  from  the  view- 
point of  pure  pathology,  but  also  in  regard  to 
treatment. 

Stenosis  from  Cicatrised  Ulcer 

It  is  without  question  that  by  cicatrisation  ulcer  is 
the  cause  of  pyloric  and  mediogastric  stenosis.  The 
ulcer  acts  in  one  of  two  ways  : — 

(1)  Cicatricial  contraction  of  the  tissues  may  go  so 
far  as  to  produce  complete  occlusion,  or  at  least  the 
resulting  stricture  is  such  that  only  fluids  can  pass 
through  its  lumen. 

(2)  Pyloric  or  juxta-pyloric  ulcer  produces  notable 
narrowing  from  infiltration  of  the  walls,  and  this 
anatomical  stricture  may  become  still  more  exag- 


THE  STENOSES  71 

gerated  from  the  influence  of  reflex  spasm  due  to 
excitation  of  the  hypersensitive  ulcer. 

Finally,  both  causes  of  stenosis  are  reinforced 
by  the  formation  of  adhesions  resulting  from  peri- 
pyloritis  and  perigastritis,  which  may  cause  bends  or 
kinks.  The  bands  and  adhesions  which  not  infre- 
quently exert  a  marked  influence  will  be  discussed 
further  on. 

Ziegler  remarked  that  ulcer  of  the  stomach  is 
usually  seated  in  the  lesser  curvature  or  the  pylorus, 
sometimes  in  the  duodenum.  At  present  we  know 
the  infinitely  greater  frequency  of  duodenal  ulcer  as 
compared  with  ulcer  of  the  stomach  or  pylorus.  But 
it  is  nevertheless  true  that  in  about  70  per  cent,  of  the 
cases  of  gastric  ulcer  the  lesion  is  seated  in  some  part 
of  the  stomach  where,  after  its  cure,  important  con- 
traction will  ensue,  resulting  in  stenosis.  As  to  duo- 
denal ulcer,  it  practically  should  be  attached  to 
pyloric  ulcer,  at  least  from  the  view-point  of  stenosis. 
Collin,  who  studied  this  subject  exhaustively,  found 
that  out  of  a  total  of  262  duodenal  ulcers,  242 
were  seated  within  about  5  centimetres  from  the 
pylorus. 

Healing  takes  place  by  proliferation  of  the  connec- 
tive and  glandular  tissues,  while  the  muscularis  never 
regenerates  when  its  fasciculi  have  been  involved  in 
the  fundus  of  the  ulcer.  Hence  it  results  that  the 
muscular  fibres  either  of  the  muscularis  or  the 
mucosa  are  interrupted  by  fibrous  tracts.  Therefore 
the  wall  of  the  stomach  loses  its  pliancy  and  elasticity, 
while  the  connective  tissue  fasciculi  always  end  by 
contracting  more  or  less. 


72  SURGICAL  TREATMENT 

When  the  wall  of  the  stomach  has  been  perforated 
or  even  when  inflammatory  processes  have  reached 
the  deep  subserous  layer  of  the  muscularis,  the  peri- 
toneum becomes  irritated  by  the  process  and  puts  up 
a  defence  by  contracting  adhesions  with  the  adjacent 
viscera.  In  these  circumstances  a  white  cicatrix  is 
found,  usually  star-shaped,  with  long  prolongations, 
with  or  without  fibrous  bands,  thereby  testifying  to 
the  former  presence  of  adhesions. 

In  some  cases  the  ulcer  assumes  a  chronic  evolu- 
tion ;  the  inflammation  persisting,  produces  an 
intense  reaction  in  the  adjacent  tissues,  while  con- 
nective tissue  proliferation  is  so  strong  that  the 
wall  of  the  stomach  may  reach  2  or  3  centimetres 
in  thickness,  so  that  by  abdominal  palpation  the 
existence  of  a  neoplasm  may  be  suspected.  Cases  are 
not  infrequent  in  which  the  surgeon  hesitates  in 
regard  to  the  exact  nature  of  this  proliferation  until 
histological  examination  demonstrates  that  it  is 
composed  of  connective  tissue. 

In  all  statistics  of  any  value  it  is  invariably 
stated  that  pylorectomy  was  done  for  a  neoplasm 
of  undetermined  nature.  The  operator  suspected 
malignant  disease,  and  histologically  the  tumour  was 
"  chronic  ulcer."  These  callous  ulcers  are  susceptible 
of  cure,  but  it  is  clear  that  their  cicatrisation  will 
readily  produce  narrowing  of  the  parts.  The  majority 
of  bilocular  stomachs  are  due  to  this  origin,  a  callous 
ulcer  of  the  lesser  curvature,  extending  on  to  the 
anterior  and  posterior  surfaces,  probably  following 
the  direction  of  the  blood-vessels. 

Hence  cicatrisation  of  the  ulcer  gives  rise  to  con- 


THE  STENOSES  78 

traction  of  varying  type,  such  as  a  more  or  less  pliant 
cicatrix,  an  indurated  cicatrix  composed  of  pro- 
liferating fibrous  connective  tissue,  or  a  cicatrix, 
usually  indurated,  with  adhesions  binding  it  to 
adjacent  organs — omentum,  pancreas,  liver,  etc. 
This  distinction  between  the  divers  types  of  stenosis 
is  essential,  because  the  same  operative  procedures 
are  not  applicable  to  all  the  cases.  According  to  the 
kind  and  shape  of  the  cicatrix,  a  given  procedure  will 
offer  real  advantages,  the  others  only  disadvantages. 

Most  writers  agree  that  when  a  stenosis  has  formed 
and  has  been  clinically  recognised  operation  is 
imperative.  But  one  must  be  sure  of  the  diagnosis. 
This  is  usually  easy  in  most  cases,  but  it  becomes  a 
matter  of  much  delicacy  to  differentiate  a  simple 
gastric  dilatation  considered  as  idiopathic,  occurring 
in  a  nervous  individual,  following  pain  and  medical 
treatment  lengthily  and  uselessly  inflicted  upon  him. 

In  the  vast  majority  of  cases  these  subjects  are 
treated  as  gastric  neurasthenics,  and  follow  regimens 
quite  as  varied  as  they  are  discouraging  until  the  day 
comes  when  laparotomy  proves  the  existence  of  an 
organic  process,  the  cause  of  all  the  patient's  trouble 
as  well  as  his  neurasthenia. 

However,  we  willingly  recognise  that  the  recent 
progress  made  in  gastric  exploration,  especially  the 
X-rays,  has  caused  these  mistaken  diagnoses  to 
become  much  less  frequent. 

The  indication  for  operation  in  stenosis  is  placed  in 
the  category  of  imperative  indications  by  most  writers, 
those  indications  in  regard  to  which  there  is  no  possible 
hesitation.  On  the  other  hand,  there  is  some  diver- 


74  SUEGICAL  TREATMENT 

gence  of  opinion  as  to  the  time  when  operation 
should  be  undertaken.  A  number  of  internists  advise 
following  von  Leube's  principles,  consisting  of  a  rest 
cure  in  bed  with  a  special  diet  for  one  month  preceding 
the  interference. 

According  to  von  Leube,  the  vomiting  and  signs  of 
stenosis  often  are  due  to  an  incompletely  healed  ulcer ; 
therefore  a  well-regulated  medical  treatment  should 
be  first  essayed,  and  not  infrequently  will  cure  the 
lesion,  with  the  result  that  the  alarming  symptoms 
will  subside.  But  if  a  sensible  amelioration  does  not 
ensue  within  a  few  weeks,  operation  should  be 
proposed. 

This  line  of  conduct  has  been  adopted  by  many 
French  physicians  and  German  surgeons.  Others, 
on  the  contrary,  believe  that  any  delay  is  not  only  a 
loss  of  time,  but  one  chance  less  for  a  favourable  out- 
come of  the  interference.  These  writers  have,  in  fact, 
noted  that  the  older  the  stenosis  the  greater  will  be 
the  difficulty  for  the  patient  to  recuperate  his  health. 
They  particularly  fear  a  decrease  of  gastric  motility 
from  prolonged  mechanical  dilatation,  which  produces 
atrophy  of  the  mucosa  from  continual  superfunction. 

Among  those  writers  who  have  especially  drawn 
attention  to  this  point  may  be  mentioned  Korte,  who 
does  not  hesitate  to  say  that  pyloric  stenosis  should 
be  operated  on  as  soon  as  it  is  recognised.  Rencki 
remarks  that  amelioration  will  be  more  rapid  in 
inverse  ratio  to  the  duration  of  the  affection  before 
operating.  Moullin,  in  a  comparative  study  of  his 
operated  cases,  believes  that  it  is  unsafe  to  lose  time 
with  medical  treatment  for  fear  of  gastric  atony. 


THE  STENOSES  75 

Hartmann  likewise  insists  on  this  point,  and  although 
believing  in  preliminary  medical  treatment  in  certain 
cases,  he  is  of  the  opinion  that  cicatricial  stenosis 
should  be  dealt  with  surgically  as  soon  as  possible, 
that  is  to  say,  as  soon  as  it  is  recognised.  He  bases 
this  assertion  on  a  comparative  study  of  his  operative 
results.  But  the  importance  of  early  operation  in 
cases  of  stenosis  is  great  from  his  point  of  view. 

Not  only  does  post-operative  treatment  require  less 
time  when  early  operation  has  been  done,  but  the 
operation  itself  is  infinitely  less  dangerous.  It  is 
clear  that  a  patient  whose  general  health  is  still  satis- 
factory would  withstand  an  operation  better  than 
another  made  cachectic  by  insufficient  feeding  and  a 
true  intoxication  from  retention. 

Hartmann's  comparative  study  is  striking  in  this 
respect :  of  thirty-six  patients  sent  him  by  Hayem 
and  Soupault,  both  partisans  of  early  interference, 
there  was  only  one  death,  otherwise  a  mortality  of 
2-8  per  cent.,  while  of  twenty-four  patients  referred 
to  him  by  other  physicians  who  had  temporised  there 
were  nine  deaths,  or  a  mortality  of  37  per  cent. 

However,  all  cases  presenting  even  very  distinct 
signs  of  pyloric  stenosis  are  not  instances  of  definite 
cicatricial  stenosis. 

Medical  treatment  may  in  certain  cases  assuredly 
cause  the  pyloric  syndrome  to  disappear,  as 
Jaworsky  and  Korczniski  have  shown.  These  are 
often  instances  of  stenosis  due  to  spasm  provoked  by 
an  unhealed  latent  ulcer  which  is  still  amenable  to 
rest  cure ;  this  is  why  one  should  always  essay  medical 
treatment  in  doubtful  cases  until  an  exact  diagnosis 


76  SUEGICAL  TREATMENT 

shall  have  been  made.  But,  as  J.  C.  Boux  has 
judiciously  remarked,  from  the  very  onset  of  treat- 
ment warn  the  patient  that  an  operation  may  still  be 
necessary.  Thus  forewarned,  the  patient  will  make 
up  his  mind  much  more  easily  and  quickly  to  submit 
to  operation  should  this  be  deemed  advisable. 

We  are  not  inclined  to  adopt  any  determined 
fixed  time,  and  prefer  to  conform  to  circumstances 
variable  in  each  case,  but  we  are  decidedly  opposed 
to  long  delay.  During  medical  treatment  the  patient 
should  be  closely  watched  in  order  to  note  the  slightest 
sign  of  gastric  atony  or,  if  this  is  already  present,  its 
persistence  or  amelioration  under  treatment.  When 
medical  measures  have  no  effect  it  is  useless  to  wait 
any  longer,  and  operation  should  be  decided  on  at 
once. 

Operations 

We  have  already  studied  the  various  procedures 
which  have  been  successively  proposed  for  the  relief 
of  stenosis,  so  that  this  subject  need  not  detain  us. 
Our  intention  is  now  to  examine  what  procedures 
give  the  best  results  according  to  the  kind  of  cicatricial 
stenosis  to  be  dealt  with.  We  have  remarked  that 
cicatricial  stenosis  may  be  pyloric  or  mediogastric. 
This  distinction  is  necessary,  because  surgical  treat- 
ment is  absolutely  different  in  each  case. 

Pyloric  Stenosis. — Pyloric  stenosis  from  healed 
ulcer  presents,  as  we  have  said,  three  different 
aspects : 

(1)  A  pliant  cicatricial  contraction,  well  localised, 
offering  little  induration  and  without  adhesions. 

(2)  Stenosis  formed  by  induration  and  thickening 


THE  STENOSES  77 

of  the  wall,  localised  to  the  pylorus,  without  extension 
to  the  adjacent  viscera. 

(3)  Induration  with  thickening  of  the  wall  extend- 
ing more  or  less  over  the  anterior  and  posterior 
aspects  of  the  stomach  or  even  to  adjacent  organs- 
liver  or  pancreas — with  many  strong  adhesions. 

Without  referring  to  Loretta's  procedure,  now  per- 
manently discarded,  the  various  procedures  to  choose 
from  are : — 

Pyloroplasty. 

Gastroduodenostomy. 

Gastroj  e j  unostomy . 

Pylorectomy. 

Pyloroplasty. — Loudly  praised  by  Mikulicz,  the 
operation  is  simple,  and  has  had  some  little  success. 
It  is  particularly  indicated  in  the  stenosis  described  in 
the  first  division  of  our  classification.  In  order  that 
Pyloroplasty  shall  be  feasible  in  favourable  con- 
ditions, the  pyloric  cicatrix  must  be  soft,  without 
thickening  or  any  very  important  adhesions.  A  few 
writers  have  given  some  precise  data  in  regard  to 
Pyloroplasty,  but  in  general  the  operation  has  not 
been  closely  studied,  so  that  the  results  so  far  obtained 
are  not  conclusive.  In  most  statistics  some  isolated 
cases  are  given,  but  it  is  not  upon  such  small  numbers 
that  an  opinion  of  any  value  can  be  based. 

Alone,  Mikulicz's  writings  give  some  data.  He 
compared  fifteen  cases  of  gastroenterostomy  with 
fourteen  definite  cures  and  one  death  with  twenty 
pyloroplasties  with  seventeen  cures  and  three  recur- 
rences. He  admitted  that  pyloroplasty  did  not  give 
such  good  results,  but,  on  the  other  hand,  it  presented 


78  SURGICAL  TREATMENT 

less  danger  than  gastroenterostomy.  In  fact,  it 
changed  the  physiology  of  gastro-duodenal  digestion 
less,  since  it  does  not  change  the  course  of  the  gastric 
contents,  as  occurs  in  gastrojejunostomy. 

Thus,  in  1905,  Rutherford  reported  twenty-eight 
cases  of  patients  who  had  been  operated  on  several 
years  previously.  Of  these  twenty-eight  cases  four 
were  subjected  to  a  second  operation  for  secondary 
stricture  resulting  from  the  plastic,  but  the  writer 
noted  that  his  patients  were  much  stronger  and  more 
vigorous  than  those  who  had  submitted  to  gastro- 
enterostomy. Rutherford,  at  this  time  at  least, 
distinctly  preferred  pyloroplasty,  and  was  opposed  to 
the  favour  accorded  to  gastroenterostomy. 

However,  few  operators  are  inclined  to  admit  that 
pyloroplasty  assures  better  gastric  functions  or  a 
more  rapid  return  to  health. 

Mikulicz  believes  that  pyloroplasty  is  particularly 
indicated  when  the  stomach  is  greatly  dilated  and 
very  atonic  ;  he  especially  fears  a  vicious  circle  in 
gastroenterostomy  done  in  these  circumstances,  but 
Carle  and  Fantino,  who  have  also  studied  the 
functional  results  of  the  operation,  do  not  agree  with 
Mikulicz  in  this  respect.  These  observers  not  only 
believe  that  the  pylorus  may  again  become  stenosed, 
but  they  have  noted  that  pyloroplasty  does  not  assure 
as  good  evacuation  as  gastroenterostomy  or  pylorec- 
tomy.  They  observed  that  great  dilatation  and 
gastric  ectasis  in  their  patients  lasted  longer  after 
pyloroplasty  than  after  gastroenterostomy,  and  they 
very  rightly  conclude  that  pyloroplasty  is  an  opera- 
tion that  may  clearly  render  service,  but  that  it 


THE  STENOSES  79 

should  be  avoided  in  cases  with  pre-operative  gastric 
atony. 

This  is  the  opinion  of  most  surgeons  of  experience, 
and  they  give  their  preference  in  general  to  gastro- 
jejunostomy.  Nevertheless  at  the  present  time, 
when  we  examine  more  closely  the  disadvantages  of 
gastro-jejunal  fistula,  and  especially  the  inconvenience 
resulting  from  exclusion  of  the  duodenum,  we  better 
comprehend  the  real  advantages  that  accrue  from 
this  operation.  It  will,  nevertheless,  always  remain 
an  operation  of  exception,  because  well-determined 
circumstances  are  necessary  for  its  performance,  and 
these  are  rarely  met  with  in  practice,  such  as  stenosis 
without  induration,  for  example.  Even  when  reserved 
for  these  indications,  it  always  exposes  to  recurrence, 
which  will  certainly  occur  more  often  than  in  other 
procedures. 

Other  than  those  cases  which  have  been  reported 
in  special  studies  of  the  subject,  the  majority  of 
isolated  case  reports  are  not  favourable  to  this 
operation.  Cramer,  of  Czerny's  clinic,  reported  seven 
cases  of  pyloroplasty  and  ninety-eight  cases  of 
gastroenterostomy.  Of  these  seven  cases  two  were 
again  operated  on  for  secondary  contraction  of  the 
pylorus,  while  of  the  ninety-eight  gastroenterostomies 
eight  secondary  operations  had  to  be  done,  four  of 
which  were  gastroenteroplasties  for  narrowing  of  the 
stoma. 

From  these  figures  it  is  clearly  evident  that  recur- 
rences are  to  be  feared,  but  it  should  be  said  that  the 
number  of  cases  given  are  insufficient  for  one  to  form 
an  idea  as  to  the  real  value  of  the  procedure.  It 


80  SURGICAL  TREATMENT 

must  not  be  forgotten  that  good  results  from  any 
procedure  are  only  obtained  when  a  surgeon  has  had 
the  opportunity  of  performing  it  frequently. 

Gastroduodenostomy,  or  Finney's  operation,  offers 
much  similarity  to  pyloroplasty.  This  procedure, 
which  may  give  excellent  results  and  presents  great 
advantages,  is  rarely  suitable  even  under  favourable 
circumstances.  As  in  the  case  of  pyloroplasty, 
gastroduodenostomy  requires  that  the  pylorus  shall 
be  pliant  and  without  induration.  It  is  especially 
essential  that  the  pyloric  antrum  and  first  portion  of 
the  duodenum  should  be  mobilised  in  order  to  be 
brought  into  approximation  with  ease. 

Like  pyloroplasty,  this  procedure  presents  the 
following  advantages  : — 

(1)  It  places  the  stoma  as  near  as  possible  to  the 
pylorus  ; 

(2)  It   avoids   the   vicious   circle  occurring   after 
gastroenterostomy  ; 

(3)  It  allows  the  gastric  contents  to  utilise  the 
duodenum. 

It  is,  however,  less  advantageous  than  pyloroplasty 
in  that  the  technique  is  more  delicate  ;  on  the  other 
hand,  it  gives  more  durable  results,  because  it  is  much 
less  prone  to  give  rise  to  secondary  contraction. 

The  indications  for  the  procedure  are  infrequent ; 
hence  it  is  not  resorted  to  often  and  is  not  generally 
well  known.  Those  who  have  employed  it  appear 
to  be  satisfied  with  the  results  obtained.  It  is  rarely 
mentioned  in  statistics,  but  we  shall  show  that, 
although  Finney's  procedure  can  only  infrequently  be 
carried  out  in  cases  of  stenosis  resulting  from  the 


THE  STENOSES  31 

cicatrix  of  an  ulcer,  favourable  anatomical  conditions 
for  this  operation  are  in  reality  much  more  frequent 
in  cases  of  stenosis  from  bands  of  adhesion,  as  the 
latter,  by  raising  the  pyloric  portion,  bring  the 
duodenum  into  contact  with  the  stomach. 

Pylorectomy. — It  is  not  our  intention  to  return  to 
the  discussion  of  the  comparative  advantages  of 
resection  and  simple  anastomosis.  It  is  natural  that 
an  uncomplicated  procedure,  such  as  gastroenteros- 
tomy,  should  be  preferred  to  a  complicated  technique 
like  pyloric  resection.  In  fact,  some  writers  recom- 
mend resection  in  cases  where  the  stenosis  is  formed 
by  an  induration  of  doubtful  pathology,  like  a  callous 
ulcer,  which  is  so  difficult  to  differentiate  from  a 
malignant  neoplasm.  Therefore,  when  in  doubt,  most 
operators  prefer  to  take  the  risks  of  a  more  laborious 
and  difficult  operation.  But,  independently  of  the 
nature  of  the  indurated  mass,  several  operators  believe 
that  it  is  better  to  excise  such  indurations,  especially 
when  they  invade  adjacent  organs,  on  the  condition 
that  this  invasion  is  not  too  extensive.  If  they  give 
preference  to  this  procedure,  it  is  because  they  fear  the 
return  of  haemorrhage  or  the  occurrence  of  perfora- 
tion, since  the  induration  is  composed  of  reactional 
connective  tissue  around  a  torpid  unhealed  ulcer,  and 
not  of  purely  cicatricial  tissue.  The  possibility  of 
malignant  transformation  in  the  old  cicatrix  is 
likewise  to  be  feared. 

As  to  the  immediate  operative  results,  they  are 
clearly  less  favourable  than  those  of  gastroenteros- 
tomy.  Cramer  has  reported  four  cases  of  death  out 
of  eight  operations,  while  there  were  only  eleven 


S.T. 


82  SURGICAL  TREATMENT 

deaths  out  of  a  total  of  ninety-eight  cases  of  gastro- 
enterostomy. 

The  functional  results  vary  greatly  with  the 
operators.  Some,  like  Mikulicz,  regard  it  as  being 
decidedly  inferior  to  other  procedures  ;  Rencki  and 
others  believe  that  the  outcome  obtained  is  about  the 
same ;  while  still  others,  especially  in  France,  believe 
that  pylorectomy  is  the  only  operation  which  can  give 
sure  and  permanent  results. 

In  a  long  article  in  the  Eevue  de  Chirurgie,  1907, 
Brechot  studies  the  physiology  of  the  duodenum  and 
the  disadvantages  of  gastroenterostomy.  According 
to  him,  the  disadvantages  are  due  to  the  fact  that 
this  important  portion  of  the  intestine — the  seat  of 
the  reflexes  necessary  for  the  production  of  the  bile 
and  pancreatic  secretions — is  not  utilised.  He  admits 
that  the  operative  mortality  of  pylorectomy  is  higher 
than  that  of  gastroenterostomy,  but  he  adds  that  if 
all  the  cases  of  death  from  late  complications,  such 
as  profuse  diarrhoea  and  perforating  peptic  ulcer,  are 
taken  into  consideration,  the  scale  will  be  higher 
in  favour  of  pylorectomy. 

Nevertheless  at  that  time  the  majority  of  surgeons 
were  partisans  of  gastroenterostomy;  and  the  most 
important  statistics,  like  those  of  Moynihan,  Mayo- 
Robson,  Monprofit,  Lambotte,  Czerny,  Kroenlein, 
etc.,  were  distinctly  favourable  to  this  procedure. 
But  of  late  years  surgeons  have  been  reverting  to  the 
more  radical  procedures. 

Gastroenterostomy. — It  is  unquestionably  in  pyloric 
stenosis  from  healed  ulcer  that  gastroenterostomy 
offers  its  principal  indications.  It  is  easy  to  discover 


THE  STENOSES  83 

the  reasons  for  its  preference  to  the  other  procedures 
already  referred  to,  and  we  have  mentioned  some  of 
them. 

Gastroenterostomy  can  be  done  in  any  case  of 
stenosis,  no  matter  how  marked  the  induration  of  the 
lesion  or  how  extensive  the  peripyloric  inflammatory 
process  may  be.  The  importance  of  adhesions  with 
adjacent  viscera  is  no  contra-indication,  because  there 
will  always  be  some  portion  of  the  gastric  wall 
accessible  and  sufficiently  mobile  for  making  a  stoma 
in  satisfactory  conditions.  Anatomical  circum- 
stances will  never  be  such  as  to  prevent  the  tech- 
nique from  being  carried  out.  The  operation  is 
infinitely  shorter  than  that  required  for  pylorectomy 
or  even  pyloroplasty,  no  matter  whether  von 
Hacker's  technique,  the  anterior  method  of  Woelfler- 
Braune,  or  the  anterior  or  posterior  Y  procedure  of 
Eoux  be  employed. 

Although  the  operative  mortality  from  resection 
has  immensely  decreased  in  recent  years,  gastro- 
enterostomy  has  nevertheless  made  greater  strides 
in  the  reduction  of  its  death-rate. 

As  to  the  functional  results  of  gastroenterostomy, 
they  are  usually  excellent,  often  extraordinary,  and 
it  is  really  uncommon  when  the  outcome  of  the 
operation  is  not  satisfactory.  The  results  obtained 
by  gastroenterostomy  in  cicatricial  stenosis  of  the 
pylorus  are  the  most  encouraging  in  the  surgery 
of  gastric  diseases  in  general,  and  we  believe  that 
this  is  the  consensus  of  opinion  to-day.  All  operators 
who  have  been  able  to  follow  their  cases  for  a  suffi- 
cient length  of  time  have  found  that  not  only  were 

o  2 


84  SUEGICAL  TREATMENT 

the  immediate  results  good  as  compared  with  other 
procedures,  but  that  the  remote  outcome  has  been 
even  better.  There  are  fewer  recurrences,  and  cases 
are  infrequent  in  which  remote  complications  have 
impaired  the  temporary  benefit  derived,  the  contrary 
opinion  of  some  writers  notwithstanding. 

If  recent  writings  in  regard  to  remote  results  of 
gastroenterostomy  be  examined,  it  will  be  found  that 
Schulz,  Cramer,  Gilli,  the  Mayos  and  others  have 
been  able  to  examine  a  certain  number  of  patients 
previously  operated  on  from  one  to  fifteen  years 
before.  From  these  statistics  it  becomes  apparent 
that  78  per  cent,  of  gastroenterostomies  for  cicatricial 
pyloric  stenosis  have  resulted  in  a  permanent  cure 
without  any  of  the  former  symptoms.  A  small 
proportion,  16*5  per  cent.,  showed  marked  improve- 
ment ;  the  patients  have  been  able  to  resume  their 
usual  mode  of  life,  although  requiring  a  more  or 
less  strict  diet  and  some  medical  care.  Finally,  in 
about  5' 5  per  cent,  no  remote  benefit  from  the 
operation  ensued. 

The  latter  cases  can  be  divided  into  two  categories  : 

(1)  Those    in    which    no    amelioration    occurred 
immediately  after  gastroenterostomy. 

(2)  Those  in  which,  after  a  more  or  less  lengthy 
period  of  cure,  the  patients  again  commenced  to  suffer 
from  the  stenosis  to  such  an  extent  that  some  were 
operated  on  a  second  or  third  time  in  order  to  obtain 
relief. 

Although  we  have  already  referred  to  the  cause  of 
these  defective  results  of  gastroenterostomy,  we  feel 
that  it  will  be  useful  to  revert  to  them  here. 


THE  STENOSES  85 

When  speaking  of  the  indications  for  operation  in 
general,  we  pointed  out  the  necessity  for  operating 
before  the  lesions  had  reached  such  a  degree  that 
atrophy  of  the  gastric  mucosa  and  muscularis  had 
taken  place.  It  is  especially  in  cicatricial  stenosis  of 
the  pylorus  that  the  stomach,  after  a  phase  of  over- 
work producing  hypertrophy  of  the  muscularis, 
becomes  at  length  atonic  from  true  exhaustion. 
This  muscular  atony,  by  increasing  stasis,  in  turn 
reacts  upon  the  gastric  chemism,  as  Doyen,  Carle  and 
Fantino  have  shown,  the  usual  outcome  being  hyper- 
secretion  and  hyperchlorhydria.  The  hypersecretion 
finally  exhausts  the  gastric  mucosa ;  and  if  stasis 
persists,  the  hypersecretion  will  rapidly  subside,  and 
in  its  stead  gastric  atrophy  develops. 

Although  gastroenterostomy  is  very  effective  in 
cases  of  hypersthenia,  it  has  little  influence  over 
atony  and  hyposecretion.  The  immediate  results 
of  the  operation  are  uncertain,  even  if  the  serious 
complications  which  readily  arise  can  be  avoided, 
such  as  vicious  circle,  so  that  a  prolonged  post- 
operative treatment  will  be  required  in  order  to  obtain 
a  merely  mediocre  functional  status. 

In  such  circumstances  is  the  operation  really  respon- 
sible for  these  disappointing  outcomes  ?  Some  writers, 
Denecheau  among  others,  do  not  hesitate  to  maintain 
the  affirmative,  but  we  believe  that  it  is  more  just  to 
assume  that  the  procedure  is  less  to  be  criticised  than 
the  fact  of  the  valuable  time  lost  in  futile  attempts  to 
cure  by  medical  treatment.  There  are  certainly  few 
instances  in  which  the  operation  should  be  held 
responsible  for  the  untoward  results. 


86  SURGICAL  TREATMENT 

As  we  have  said,  gastroenterostomy  presents 
dangers  and  disadvantages,  the  most  important  of 
which  is  vicious  circle,  or  in  a  lesser  degree  what  with 
Tavel  we  have  denominated  by  reflux.  It  is  needless 
to  revert  to  these  complications  here,  but  we  would 
say  that  reflux  is  not  invariably  fatal,  that  it  is  com- 
patible with  a  long  survival,  although  giving  rise  to 
serious  disturbances.  A  more  or  less  accentuated 
reflux  is  favoured  by  several  circumstances  ;  often 
little  mistakes  in  technique  will  for  ever  compromise 
the  success  of  the  interference. 

Gastroenterostomy  is  a  particularly  delicate  opera- 
tion, requiring  the  greatest  attention  to  every  technical 
detail,  but  when  carried  out  correctly  on  a  stomach 
which  is  not  in  a  too  advanced  state  of  atrophy  it  will 
invariably  give  excellent  results  in  pyloric  stenosis. 

More  numerous  are  the  causes  of  remote  defective 
results,  such  as  relapse  of  the  ulcer.  We  have  already 
considered  the  various  causes  of  imperfect  functions 
of  the  stoma  in  general,  so  we  shall  not  revert  to  them 
here ;  there  is,  however,  one  that  should  be  men- 
tioned, as  it  is  not  generally  recognised,  therefore  not 
often  referred  to,  namely,  closure  of  an  unutilised 
stoma.  This  occurs  when  the  stenosis  is  not  complete. 
The  lumen  of  the  pylorus,  although  greatly  reduced 
in  calibre,  allows  some  of  the  gastric  contents  to  pass 
through  it.  If  an  anastomosis  is  done  for  symptoms 
of  retention  due  not  only  to  stenosis,  but  also  to 
defective  motility,  the  results  will  at  first  be  excellent : 
the  stomach  will  empty  itself  through  the  new  stoma, 
and  the  gastric  dilatation  will  diminish,  while  the 
musculature  will  regain  strength.  At  the  same  time, 


THE  STENOSES  87 

the  pylorus  being  put  to  rest,  the  neighbouring 
tissue  infiltration  present  will  subside;  hence  the 
stenosis  will  be  lessened.  The  pylorus  becoming  more 
permeable  and  the  musculature  regaining  its  activity, 
the  gastric  contents  will  follow  their  normal  course 
through  the  pylorus.  During  this  time  the  stoma 
will  not  be  utilised.  In  fact,  we  know  by  the  experi- 
ments of  Kelling  and  Clumsky,  as  well  as  by 
numerous  radiographical  examinations,  that  when 
the  pylorus  is  permeable  all  gastro-intestinal  transit 
takes  place  by  this  route,  and  that  the  stoma  is 
abandoned.  As  it  is  no  longer  regularly  dilated  by 
the  passage  of  the  food,  the  stoma  closes  with  what 
might  seem  to  be  surprising  rapidity  were  it  not 
known  with  what  ease  gastrostomy  openings  close 
when  left  alone. 

What  takes  place  in  these  circumstances  ?  The 
stoma  becomes  completely  occluded,  so  that  the 
intestine  has  even  been  known  to  become  per- 
manently separated  from  the  stomach.  In  fact, 
Turner,  Monprofit,  Koux  and  others  have  been  unable 
to  discover  any  trace  of  a  gastroenterostomy  that 
they  had  performed  several  years  previously.  In 
some  cases  this  temporary  operation  may  be  very 
salutary,  when,  for  example,  it  has  allowed  a  pre- 
pyloric  ulcer  to  heal  in  good  conditions  :  once  the 
ulcer  is  cicatrised,  the  stomach  is  emptied  by  the 
normal  route,  and  the  symptoms  of  stenosis  will  not 
return. 

But  in  many  cases  the  passage  of  food  over  a  still 
fresh  cicatrix  or  over  even  less  sensitive  tissues  may 
by  the  continued  irritation  produce  an  inflammatory 


88 

reaction  with  progressive  stenosis  formation.  It  is 
just  at  this  time  that  the  stoma  should  be  of  use,  but 
unfortunately,  being  also  stenosed  from  disuse,  it  does 
not  allow  the  passage  of  any  of  the  gastric  contents, 
with  the  result  that  the  stomach  again  dilates. 

This  perhaps  somewhat  theoretical  explanation  of 
recurrence  is  based  on  the  study  of  various  articles  on 
the  functions  of  the  gastroenterostomy  stomata  with 
a  permeable  pylorus.  Hence  the  late  Professor 
Girard  was  led  to  propose  a  complementary  operation 
in  order  to  avoid  recurrences,  which  assures  regular 
and  permanent  functions  of  the  stoma.  The  opera- 
tion consists  of  exclusion  of  the  pylorus.  It  was 
formerly  practised  by  Eiselsberg  and  Doyen,  who 
recommended  it  especially  in  cases  of  hsemorrhagic 
pyloric  ulcer. 

In  this  way  the  pylorus  is  permanently  closed.  The 
gastric  contents  will  pass  by  the  stoma,  which  is  the 
surest  means  of  always  keeping  it  patent.  It  is  true 
that  pyloric  exclusion  will  prolong  the  duration  of  the 
interference,  likewise  the  danger ;  nevertheless  it  is 
an  infinitely  simpler  and  more  rapid  technique  than 
pylorectomy. 

It  is  especially  indicated  in  gastroenterostomy  for 
ulcer,  particularly  the  haemorrhagic  type.  Naturally 
quite  superfluous  in  complete  cicatricial  stenosis,  it  is, 
however,  necessary  in  incomplete  stenosis,  even 
when  essentially  fibrous  in  nature,  or  appearing  as 
such.  In  fact,  one  can  never  be  certain  that  under 
the  sclerous  tissue  a  latent  ulcer  giving  rise  to  no 
symptoms  does  not  keep  up  a  stenosing  action, 
although  at  a  given  time  it  may  retrogress  to 


THE  STENOSES  89 

such  an  extent  that  the  pylorus  becomes  freely 
permeable. 

Therefore  in  exclusion  of  the  pylorus  we  possess  a 
relatively  simple  means,  devoid  of  danger,  of 
avoiding  late  recurrence,  which  has  been  one  of  the 
arguments  put  forward  by  the  opponents  of  gastro- 
enterostomy.  We  feel  prepared  to  say  from  personal 
experience  that  this  procedure,  as  yet  little  known  and 
rarely  resorted  to,  will  be  employed  more  and  more, 
and  by  so  doing  the  already  small  number  of  cases  of 
defective  function  of  the  stoma  following  gastro- 
enterostomy  will  be  still  more  reduced. 

The  most  direct  effect  of  gastroenterostomy  is  to 
prevent  stasis  and  hence  to  overcome  gastric  dilata- 
tion. The  decrease  of  gastric  ectasis  varies  enor- 
mously according  to  the  case,  and  writers  do  not 
always  agree  on  this  subject.  It  depends  essentially 
upon  the  state  of  the  musculature  before  operation. 
Out  of  a  total  of  eighty-two  examinations  Gilli  esti- 
mates that  in  50  per  cent,  of  the  cases  the  gastric 
capacity  becomes  normal.  Carle  and  Fantino,  the 
first  to  examine  this  special  subject,  found  that 
gastric  dilatation  usually  decreases,  but  that  the 
stomach  rarely  returns  to  its  normal  size.  In  the 
majority  of  operated  cases  the  stomach  empties  its 
contents  well,  the  phenomena  of  stasis  subside,  but 
the  evacuation  takes  place  more  slowly  than  in  normal 
stomachs.  An  hour  after  Ewald's  test  meal  these 
observers  found  the  stomach  almost  full ;  it  only  com- 
pletely empties  itself  after  three  hours.  They  believe 
that  the  stoma  is  provided  with  a  kind  of  sphincter, 
which  takes  some  time  to  regulate  its  functions. 


90  SURGICAL  TREATMENT 

Out  of  fourteen  cases  Rendu  noted  a  marked 
amelioration  of  the  gastric  motility  in  thirteen,  and 
found  that  the  longer  the  time  since  operation  the 
more  accentuated  is  the  improvement.  Out  of  thirty- 
five  cases  examined  by  Cramer  seven  showed 
accelerated  evacuation,  in  thirteen  it  was  normal,  and 
in  fifteen  it  was  still  slow,  but  in  only  one  of  these 
fifteen  were  there  symptoms  of  stasis. 

Hartmann  and  Soupault  believe  that  the  gastric 
capacity  usually  becomes  normal,  but  they  note 
great  differences  in  different  cases.  The  stomach 
assumes  average  dimensions  after  a  variable  lapse  of 
time,  this  depending  upon  the  degree  of  dilatation 
before  operation  was  resorted  to.  The  cases  in  which 
the  operation  gave  the  best  and  most  rapid  results 
were  those  in  which  a  rapidly  formed  and  tight 
stenosis  had  resulted  in  moderate  gastric  dilatation. 

As  to  the  motility,  these  observers  believe  that 
the  operation  produces  notable  improvement  in  the 
transit  of  the  gastric  contents,  but  they  have  never 
seen  it  return  to  normal  even  in  patients  examined 
a  year  after  the  interference.  They  always  found 
traces  of  Ewald's  test  meal  one  hour  and  a  half  after 
ingestion.  However,  they  do  not  believe  that  there  is 
any  sphincter  formation  arising  in  the  stoma,  as  is 
supposed  by  Carle  and  Fantino  to  be  the  case. 

These  different  examinations  show  that  in  the  great 
majority  of  cases  the  gastric  capacity  tends  to  become 
normal,  and  this  more  or  less  rapidly  according  to 
the  previous  state  of  the  walls  of  the  stomach.  On 
the  other  hand,  gastric  evacuation  is  not  apt  to  return 
to  normal ;  slow  emptying  of  the  stomach  usually 


THE  STENOSES  91 

persists,  although  giving  rise  to  no  symptoms.  This 
also  tends  to  diminish,  but  a  return  to  the  norm  takes 
place  less  quickly  than  that  of  gastric  dilatation. 

In  a  number  of  articles  published  precise  indica- 
tions are  given  as  to  the  disappearance  of  stasis 
following  gastroenterostomy.  We  will  give  the 
results  of  studies  made  on  statistics  of  sufficient 
importance  to  be  seriously  considered  : — 

Graf  noted  improvement  of  the  gastric  motility  in 
75  per  cent,  of  the  cases  with  disappearance  of  the 
phenomena  of  stasis. 

Petersen  found  amelioration  of  the  gastric  motility 
in  85  per  cent,  of  the  cases. 

Krausch  admits  that  in  80  per  cent,  of  the  cases  a 
return  to  normal  evacuation  of  the  stomach  may  be 
anticipated. 

Finally,  Carle  and  Fantino  conclude  their  study  by 
saying  that  the  improvement  of  motility  is  the  rule, 
but  that  it  is  never  normal.  Gastric  evacuation  takes 
place  completely,  but  in  the  vast  majority  of  cases  it 
is  slower  than  normal. 

These  percentages  are  very  encouraging,  but  the 
favourable  effects  of  gastroenterostomy  are  not  con- 
fined to  them.  In  fact,  one  of  the  symptoms  often 
present  with  stasis,  namely,  hyperchlorhydria,  also 
decreases  in  remarkable  proportions.  We  shall 
again  refer  more  in  detail  to  this  special  action  of  the 
operation  when  speaking  of  the  treatment  of  simple 
ulcer  by  gastroenterostomy,  in  which  this  influence 
assumes  an  infinitely  greater  importance.  Let  us  say 
here  that  in  the  majority  of  cases  the  anastomosis 
produces  a  marked  decrease  of  the  acidity,  whatever 


92  SURGICAL  TREATMENT 

may  be  said  to  the  contrary  notwithstanding — to  the 
norm  or  even  below.  The  majority  of  writers  who 
have  examined  the  gastric  chemism  before  operation 
agree  on  this  point.  On  the  other  hand,  their 
explanations  differ  ;  several  theories  have  been  put 
forward,  which  we  shall  examine  further  on. 

In  this  respect  gastroenterostomy  has  a  more 
constant  and  rapid  effect  than  other  procedures— 
pyloroplasty,  gastroduodenostomy,  etc.  Pylorec- 
tomy,  according  to  the  technique  employed,  may 
have  a  like  action.  The  decrease  of  the  acidity  is 
especially  pronounced  after  this  operation  when 
Billroth  II.  has  been  done,  of  which  one  of  the  steps 
is  anastomosis. 

It  ensues  from  this  examination  of  the  comparative 
advantages  of  various  procedures  that  may  be 
resorted  to  for  obviating  cicatricial  pyloric  stenosis 
that  the  surgeon  has  a  choice  between  several  opera- 
tions. Before  operation  it  is  impossible  to  decide 
which  procedure  shall  be  adopted,  as  this  will  depend 
upon  the  anatomical  site  of  the  ulcer,  but  this  cannot 
be  located  with  any  degree  of  certitude  until  the 
stomach  is  in  the  operator's  hands.  According  to 
the  condition  of  the  pylorus — indurated,  pliant, 
adherent  or  mobile — the  operator  can  do  a  pylorec- 
tomy,  pyloroplasty,  gastroduodenostomy  or  gastro- 
enterostomy. According  to  the  conditions  present, 
one  or  other  of  these  procedures  will  be  carried 
out,  but  it  should  never  be  forgotten  that  there  are 
certain  formal  contra-indications  inherent  to  some  of 
them. 

Gastroenterostomy  is  the  only  procedure  that  can 


THE  STENOSES  93 

always  be  resorted  to  ;  and  when  its  technique  is 
properly  carried  out  in  each  detail,  it  will  give  sure 
results  if  when  indicated  exclusion  of  the  pylorus 
be  combined  with  it.  The  advantages  claimed  by 
some  surgeons  for  pyloroplasty,  gastroduodenostomy 
and  pylorectomy,  are  clearly  counterbalanced  by  the 
rapidity  of  execution,  the  certainty  of  the  results 
obtained  and  the  small  danger  when  gastroenteros- 
tomy  is  performed.  This  operation  is  probably  at 
the  present  time  the  method  of  choice  among  the 
majority  of  operators  in  cases  of  pyloric  stenosis  from 
healed  ulcer. 

Stenoses  due  to  Cicatrices  of  Burns  from  Caustics 

Stenoses  following  burns  from  caustics  offer  much 
analogy  with  stenoses  following  upon  ulcer.  How- 
ever, they  present  some  differences  that  it  is  well  to 
mention,  both  from  the  anatomical  view-point  as  well 
as  that  of  treatment. 

Gastric  stenoses  from  ingestion  of  caustic  fluids 
may  be,  like  ordinary  cicatricial  stenosis,  pyloric  or 
mediogastric  ;  at  least  these  are  the  two  most  frequent 
localisations  of  burns.  That  a  caustic  can  be  absorbed 
without  attacking  the  upper  digestive  tract  is  well 
known,  but  in  most  cases  it  will  produce  serious 
lesions  of  the  stomach.  This  anomaly  is  readily 
explained.  The  fluid  passing  quickly  through  the 
oesophagus  surrounded  by  an  abundant  layer  of 
mucus,  reaches  the  stomach,  where  it  is  retained  for  a 
certain  length  of  time.  The  contact  of  the  caustic 
with  the  gastric  mucosa  being  more  prolonged,  this 
membrane  is  all  the  more  profoundly  involved 


94  SURGICAL  TREATMENT 

Stenoses  resulting  from  caustics  are  consequently 
localised  at  those  spots  where  the  traumatic  agent 
remains  the  longest.  Now  there  are  two  areas 
particularly  exposed,  namely,  the  pylorus  and  the 
mid-region  of  the  stomach,  which  represents  the 
boundary  between  the  cardiac  portion  and  prepyloric 
antrum.  These  two  regions  correspond  to  sphincters, 
the  one  pyloric,  an  anatomically  constituted  sphinc- 
ter, the  other  limiting  the  prepyloric  portion  more 
physiologically  than  anatomically.  The  muscular 
contractions  formed  by  these  two  barriers  are  con- 
trolled by  reflexes  whose  starting-point  is  an  excita- 
tion of  the  gastric  mucosa.  Researches  carried  out 
by  means  of  experimental  fistulae  (Kelling)  or  radio- 
scopic  examination  of  the  normal  gastric  functions 
have  demonstrated  these  facts.  Hence  we  under- 
stand why  the  caustic  fluid  acts  on  the  pylorus  or  the 
mediogastric  region  in  the  vast  majority  of  cases, 
leaving  the  cul-de-sac  of  the  stomach  intact. 

Several  writers,  Ferret  among  others,  admit  that 
the  caustic  goes  directly  from  the  cardia  to  the 
pylorus  following  the  lesser  curvature,  and  this 
hypothesis  is  accepted  by  Le  Dentu  and  Delbet. 
They  thus  explain  the  pyloric  localisation  so  special 
to  ulcer  caused  by  caustics.  But  if  this  hypothesis  be 
accepted,  how  can  the  mediogastric  localisation  be 
accounted  for,  which  is  much  less  infrequent  than  is 
generally  supposed  ? 

It  appears  to  us  more  exact  to  admit  that  this 
almost  constant  localisation  of  the  effects  of  the 
caustic  is  determined  by  the  arrest  and  sojourn  of  the 
caustic  at  these  two  points  for  a  variable  length  of 


THE  STENOSES  95 

time,  while  it  rapidly  traverses  the  region  of  the  cardia 
and  greater  curvature.  After  having  been  retained 
for  a  variable  length  of  time  at  the  mid-portion,  it  is 
pushed  on  to  the  pylorus,  where  another  and  generally 
longer  arrest  produces  still  graver  lesions. 

Stenosis  from  burns  is  different  from  stenosis 
from  ulcer  in  that  the  process  is  usually  double.  A 
bilocular  stomach  is  formed,  generally  with  very 
unequal  pouches,  the  cardiac  pouch  being  very  large, 
the  pyloric  pouch  much  reduced  in  size,  and  from  this 
fact  the  biloculation  has  been  overlooked  at  opera- 
tion. The  mediogastric  stenosis  has  been  mistaken 
for  simple  pyloric  stenosis,  but  a  careful  examination 
would  have  revealed  the  true  condition  of  affairs. 

Stenosis  from  caustics  also  differs  from  ordinary 
cicatricial  stenosis  by  its  generally  very  rapid  evolu- 
tion. In  about  four  to  six  weeks  after  ingestion  of 
the  caustic  symptoms  of  stenosis  are  already  very 
manifest.  Medical  treatment  will  have  had  little 
effect  on  the  rapidly  progressive  evolution  of  the 
lesions,  so  that  urgent  operative  interference  is 
required. 

However,  in  some  cases  the  appearance  of  the 
symptoms  has  been  delayed.  It  may  be  supposed 
that  in  these  circumstances  there  has  been  exhaustion 
and  secondary  atrophy  of  the  muscularis,  which  can 
no  longer  force  the  gastric  contents  through  the 
narrowed,  but  still  patent,  lumen  of  the  pylorus,  rather 
than  a  tardy  development  of  the  stenosis.  Hence 
gastric  stasis  ensues,  with  its  train  of  symptoms,  as  is 
the  case  in  stenosis  from  ulcer. 

Medical    treatment    is    powerless.     In    cases    of 


96  SURGICAL  TREATMENT 

incomplete  occlusion  it  may  possibly  prevent  exhaus- 
tion of  the  muscularis,  but  its  effect  is  confined  to  this 
one  element.  Therefore  operative  treatment  is 
absolutely  indicated  ;  the  evolution  of  the  process  is 
rapid  :  hence  surgical  interference  is  required  as  soon 
as  the  symptoms  of  stenosis  appear. 

As  to  the  best  procedure  to  be  employed,  we 
have  discussed  this  subject  in  the  foregoing  pages  ; 
we  attempted  to  show  the  respective  advantages  of 
each  according  to  the  circumstances  present,  so  that 
we  need  not  revert  to  the  subject  again.  We  would 
merely  remark  that  bilocular  stomach  is  more 
common  after  burns  than  ulcer,  and  that  the  gastric 
pouches  are  very  unequal  in  size.  This  biloculation, 
which  has  been  referred  to  in  order  to  explain  the 
localisation  of  the  stenosis,  is  theoretically  important. 
The  prepyloric  pouch,  usually  reduced  to  very  small 
proportions  and  often  completely  stenosed,  does  not 
in  the  majority  of  cases  even  merit  the  surgeon's 
attention. 

The  procedure  of  double  gastroenterostomy  as 
practised  by  Clement  and  Monprofit  is  in  most  cases 
perfectly  superfluous,  since  simple  gastroenterostomy 
assures  good  evacuation,  and  hence  is  thoroughly 
sufficient.  It  is,  for  that  matter,  the  procedure 
generally  employed,  and  gives  satisfaction. 

As  to  various  other  procedures,  such  as  gastro- 
plasty,  pyloroplasty,  gastroduodenostomy  and  gas- 
troanastomosis,  they  may  likewise  give  excellent 
results,  but  they  offer  the  same  disadvantages  as  in 
cases  of  stenosis  from  ulcer.  In  the  cases  under 
consideration  the  cicatrix  is  often  large,  indurated, 


THE  STENOSES  97 

surrounded  by  a  more  or  less  considerable  area  of 
sclerosed  tissue,  which  does  not  lend  itself  to  the 
performance  of  delicate  techniques  or  exact  suturing. 

In  the  case  of  severe  burns,  which  may  involve 
the  entire  mucosa  of  the  stomach,  contraction  of  the 
viscus  may  be  such  that  an  anastomosis  can  only  be 
performed  with  considerable  difficulty.  In  these 
circumstances  the  rational  procedure,  the  one  which 
gives  excellent  results,  is  duodenostomy  or  even 
jejunostomy.  The  former  is  in  reality  rarely 
feasible  on  account  of  the  strong  adhesions  that  are 
usually  present  in  extensive  deep  burns. 

Von  Eiselsberg,  the  promoter  of  this  procedure, 
has  been  satisfied  with  it.  He  points  out  that 
in  cases  of  serious  retraction  of  the  stomach  the 
caustic  agent  will  have  at  the  same  time  usually 
produced  stenosis  of  the  oesophagus  and  cardia. 
After  jejunostomy  these  strictures  can  be  dealt  with 
in  a  much  more  complete  fashion. 

In  this  we  find  one  of  the  best  indications  for  this 
procedure.  It  is  at  the  same  time  one  of  the  most 
frequent.  The  changes  arising  in  the  stomach 
following  ulcer  are  rarely  sufficiently  profound  to 
oblige  the  surgeon  to  have  recourse  to  this  extreme 
measure,  which  will  infrequently  be  accepted  by  the 
patient ;  and  it  is  only  when  the  patient  has  arrived 
at  the  ultimate  degree  of  inanition  that  he  will 
submit. 

The  results  of  the  various  procedures  described  are 
usually  excellent.  The  cases  are  too  few  in  number 
to  make  a  comparison  between  the  results  obtained  in 
stenosis  from  ulcer  and  those  in  stenosis  from  burns. 

S.T.  H 


98  SURGICAL  TREATMENT 

In  order  that  such  a  comparison  should  be  conclusive 
it  would  be  necessary  to  have  the  statistics  of 
patients  operated  on  by  the  same  surgeon  and  by  the 
same  procedure.  Nevertheless  the  cases  scattered 
throughout  medical  literature  show  that  the  patients 
support  the  interference  as  well  as  patients  with 
stenosis  from  ulcer,  and  that  the  benefit  accruing 
is  quite  as  durable. 

It  is  clear  that  the  results  largely  depend  upon 
the  extent  of  the  lesions,  the  more  or  less  pronounced 
state  of  the  sclerosis  and  degeneration  of  the 
mucosa.  Generally  speaking,  the  gastric  chemism 
is  less  disturbed  than  in  stenosis  from  ulcer,  and 
because  of  this — the  lesions  being,  above  all, 
mechanical  in  nature — any  procedure  having  for 
result  the  regular  evacuation  of  the  stomach  will  give 
both  a  rapid  and  durable  cure. 

Congenital  Stenoses  of  the  Pylorus 

The  stenoses  usually  comprised  under  the  heading 
of  congenital  pyloric  stenosis  may  be  divided  into 
two  classes,  which  differ  essentially  in  regard  to  their 
pathology.  Those  that  are  unquestionably  con- 
genital are  rare  ;  the  others — the  more  frequent — 
would  be  more  correctly  called  pyloric  stenoses  of 
nurslings.  They  have,  in  fact,  a  distinctly  special 
evolution. 

This  distinction  was  made  by  Weil  and  Pehu  in 
their  excellent  general  study  of  this  type  of  stenosis. 
They  distinguished  three  clinical  forms  of  the  so- 
called  congenital  pyloric  stenosis. 

(1)  The  true  congenital  variety  is  an  atresia  due 


THE  STENOSES  99 

to  defective  development,  a  complete  imperf oration 
or  stricture  of  the  pylorus  the  result  of  incomplete 
development  or  some  intra-uterine  affection. 

(2)  The    hypertrophic    variety,    constituted     by 
muscular  hypertrophy,  a  true  pyloric  myoma,  which 
produces  stenosis,  often  almost  total. 

(3)  The  spasmodic  variety,  due  to  a  more  or  less 
accentuated  spasm  of  the  pylorus. 

The  last  two  varieties  of  stenosis  are  very  closely 
allied  in  regard  to  symptomatology  and  evolution. 
Several  writers,  Pfaundler  in  particular,  maintain 
that  there  is  no  difference  between  them,  and  that 
they  are  one  and  the  same  variety.  Their  view-point 
is  that  the  permanent  hypertrophy  of  the  pylorus 
does  not  exist  and  is  only  due  to  spasmodic  contrac- 
tion of  the  muscularis. 

True  congenital  stenoses  are,  like  all  other  conge- 
nital defects,  of  debatable  origin.  More  frequent 
than  atresia  of  other  portions  of  the  digestive  tract, 
with  the  exception  of  the  anus  and  oesophagus, 
pyloric  stenosis  is  favoured  by  the  fact  that  the 
sphincteric  portion  is  situated  between  a  fixed  point — 
the  duodenum — and  a  mobile  viscus — the  stomach — 
which  changes  its  shape  and  direction  at  a  given  time 
during  embryonal  development.  This  particular 
point  is  more  exposed  than  any  other  to  bends  and 
kinks,  as  well  as  to  tractions  which  may  engender 
disturbances  of  the  vascular  supply  or  favour 
inflammatory  lesions  at  this  point. 

These  congenital  atresias  have  early  vomiting  as  a 
cardinal  symptom,  arising  immediately  after  birth. 
The  rapidly  progressive  exhaustion  of  the  infant  is 

H  2 


100  SUKGICAL  TREATMENT 

often  an  obstacle  to  surgical  treatment,  the  only  one 
that  can  effect  any  relief. 

Anatomical  examinations  that  have  been  carried 
out  in  cases  of  this  kind  have  shown  all  degrees  of 
atresia,  from  complete  separation  of  the  stomach  and 
duodenum  to  obliteration  of  the  pyloric  canal,  which 
has  become  transformed  into  a  more  or  less  long 
fibrous  cord. 

The  only  surgical  procedure  indicated  is  gastro- 
enterostomy,  the  anatomical  conditions  hardly 
lending  themselves  to  pylorectomy,  which  would 
anyway  be  out  of  the  question  in  infants.  At  the 
best  gastroenterostomy  is  more  than  serious,  given 
the  age  and  poor  physical  condition  of  these  infants, 
so  that  recovery  from  the  operation  can  hardly  be 
anticipated. 

The  so-called  hypertrophic  stenoses  are  more 
frequently  met  with,  and  are,  therefore,  better  known. 
They  differ  from  the  preceding  lesion  in  the  fact 
that  the  alarming  symptoms,  particularly  the  vomit- 
ing, do  not  usually  appear  until  the  beginning  of  the 
third  week  of  life.  Until  then,  the  infant  develops 
and  increases  in  weight  in  a  perfectly  normal  way,  as 
the  charts  published  by  Dufour  and  Predet  show. 
According  to  these  observers,  it  is  about  the  twentieth 
day  that  the  pyloric  syndrome  of  nurslings  makes  its 
appearance.  It  is  at  this  time  that  arrest  of  the 
infant's  growth  commences,  and  it  is  then  that  the 
attending  physician  must  decide  what  had  better  be 
done. 

In  reality  the  pyloric  syndrome  of  nurslings  may 
be  due  to  one  of  two  causes  difficult  to  differentiate, 


THE  STENOSES  101 

namely,  a  spasm  producing  hypertrophy  or  pure 
hypertrophy.  The  distinction  is  often  very  difficult 
to  make,  but  nevertheless  is  necessary,  because  the 
treatment  essentially  depends  upon  this  diagnosis- 
medical  treatment  in  the  case  of  spasm,  surgical  in 
hypertrophy. 

When  there  is  a  suspected  diagnosis  of  congenital 
pyloric  stenosis,  the  infant  should  be  placed  flat  on 
its  back  and  given  30  c.c.  of  sugar  water.  When  this 
has  been  ingested,  typical  peristaltic  waves  will  be 
seen  crossing  the  abdomen  from  the  left  hypochon- 
driac region  obliquely  to  the  right.  If  more  sugar 
water  be  given,  the  stomach  balloons  out  in  tonic 
contraction.  Then  very  strong  retroperistaltic  waves 
become  manifest,  followed  by  projectile  vomiting. 
These  signs  are  almost  certain  indications  of  pyloric 
stenosis. 

To  complete  the  diagnosis  the  infant  is  placed 
under  a  horizontal  fluoroscope  and  allowed  to  feed 
from  a  bottle  containing  bismuth-milk,  and  the 
passage  through  the  oesophagus  is  watched.  If  the 
infant  lies  flat  on  its  back,  the  bismuth-milk  collects 
on  the  left  side  of  the  spine  as  a  large  round  mass  and 
remains  there  indefinitely.  If  the  subject  be  turned 
to  the  right,  almost  on  its  abdomen,  the  bismuth  will 
be  seen  to  gradually  gravitate  toward  the  pyloric 
end  of  the  stomach,  while  peristaltic  waves  will  be  at 
once  seen  in  the  pyloric  antrum  and  pylorus.  A 
small  amount  of  bismuth  is  forced  through,  and  then 
the  pylorus  shuts  down  tightly.  Immediately  after 
peculiar  rhythmical,  snake-like  pyloric  contractions 
become  visible,  quite  independent  of  the  rest  of  the 


102  SURGICAL  TREATMENT 

stomach,  and  these,  according  to  Ahrens  and  Strauss, 
of  Chicago,  are  absolutely  characteristic. 

At  the  end  of  two  hours  roentgenograms  are  taken. 
In  some  cases  Ahrens  and  Strauss  have  observed 
retroperistaltic  waves  in  the  body  of  the  stomach  with 
coincident  dilatation  of  the  oesophagus,  this  probably 
being  due  to  retroperistalsis.  The  emptying  time  of 
the  stomach  has  been  standardised,  so  that  in  any 
case  in  which  one  half  or  more  of  the  bismuth-milk 
remains  at  the  end  of  four  hours  a  diagnosis  of  pyloric 
stenosis  is  made.  Cases  in  which  80  per  cent,  or 
more  of  the  bismuth-milk  has  passed  through  the 
pylorus  at  the  end  of  four  hours  can  usually  be  cured 
by  medical  treatment. 

We  are  prepared,  from  our  personal  experience,  to 
unhesitatingly  admit  that  both  conditions — spasm 
and  hypertrophy — separately  exist,  and  this  seems 
to  be  the  opinion  of  most  writers  on  the  subject.  It 
would,  in  fact,  be  difficult  to  admit  that  simple 
spasmodic  contractions,  even  tetanic  in  nature, 
could  produce  such  extensive  hypertrophy  of  the 
pyloric  muscularis. 

In  true  hypertrophy  we  have  always  been  able  to 
detect  a  pyloric  tumour,  and  in  some  cases  have 
based  our  diagnosis  on  this  sign  alone,  but  not  in  all. 
When  there  is  any  doubt  as  to  the  differential 
diagnosis  between  spasm  and  hypertrophic  stenosis, 
the  success  or  failure  of  medical  treatment  will  settle 
the  question,  and  upon  it  will  depend  the  indication 
for  surgical  interference. 

Surgical  treatment  of  these  cases  is  unquestionably 
serious  and  should  not  be  proposed  \vith  a  light  heart. 


THE  STENOSES  103 

Out  of  a  total  of  twelve  gastroenterostomies  for  con- 
genital hypertrophic  stenosis  of  the  pylorus  four  of 
our  patients  succumbed,  a  mortality  of  33  per  cent. 

Out  of  a  total  of  135  cases  operated  on  up  to  the 
end  of  1907  we  find  a  mortality  of  48  per  cent.,  but 
these  cases  were  dealt  with  by  various  interferences, 
as  the  following  table  shows  : — 

Per  cent. 

Two     exploratory     laparo- 

tomies        Mortality  =  100 

One  jejunostomy      . .         . .  ,,  =  100 

One  pylorectomy     . .         . .  „  =100 

Fifty-two  gastroenterostomies  „  =    57*6 

Twenty-two     pyloroplasties  „  =    40*9 
Seven  divulsions  with  gastro- 

enterostomy         . .         . .  „  =    14-2 

Six  submucous  plastics  with 

dilatation  . .         . .         . .  „  =    16*6 

Eight  cases,  nature  of  opera- 
tion unknown       . .         . .  „  =75 

It  is  to  be  noted  that  in  1906  Thompson  gave  the 
total  mortality  as  53  per  cent.,  while  in  1914  Scudder 
reported  a  mortality  of  14  per  cent,  following  gastro- 
enterostomy  at  the  hands  of  good  operators. 

Dufour  and  Fredet  long  since  maintained  that 
submucous  pyloroplasty  was  the  method  of  choice : 
it  gives  the  lowest  mortality,  because  the  procedure 
is  both  simple  and  rapid  in  execution.  Unfortu- 
nately this  procedure  is  not  always  applicable.  In 
reality  the  muscularis  is  sometimes  so  hypertrophied 
that  the  lumen  of  the  pyloric  canal  cannot  be  increased 
in  calibre  by  a  simple  incision  which  suture  will 


104  SURGICAL  TREATMENT 

change.  Given  the  high  mortality  in  the  hands  of 
experienced  operators,  any  procedure  that  can  reduce 
it  would  be  most  acceptable,  and  therefore  we  would 
briefly  describe  the  technique  of  pyloroplasty  as 
devised  by  Strauss,  of  Chicago,  in  1913.  The  pro- 
cedure has  for  its  object  the  transformation  of  the 
pathologic  form  of  pylorus  into  a  normal  one.  The 
pyloric  tumour  shows  on  cross-section  that  it  has, 
first,  an  infolding  of  its  mucosa,  and,  secondly,  a 
tumour  composed  of  hypertrophied  normal  striated 
muscle.  To  reconstruct  a  normal  pylorus  the  infold- 
ing mucosa  must  be  unfolded  by  shelling  it  out,  and 
after  this  has  been  done  the  muscular  tumour  must 
be  reduced  by  using  it  as  a  plastic  flap.  Strauss  has 
operated  on  103  cases  of  congenital  pyloric  stenosis 
by  his  method,  with  three  deaths.  As  the  results  are 
so  remarkable  and  as  the  technique  of  the  procedure 
is  relatively  new,  Strauss  having  published  it  in  1915, 
we  shall  give  it  in  outline. 

An  incision  2J  centimetres  long  is  made  in  the 
right  rectus  muscle,  beginning  in  the  right  hypochon- 
drium.  This  admits  the  index  finger,  which  can  then 
palpate  the  pyloric  tumour.  A  fine  ribbon-shaped 
hook  is  then  introduced  into  the  wound  along  the 
index  finger  to  the  tumour,  which  is  then  brought  up 
by  means  of  the  hook.  Therefore  there  is  no 
handling  or  exposure  of  anything  but  the  pyloric 
end  of  the  stomach.  An  incision  is  then  made  over 
the  more  bloodless  portion  of  the  tumour  and  carried 
down  almost  to  its  duodenal  end.  Only  the  super- 
ficial layers  are  cut.  The  remainder  of  the  tumour 
is  now  split  with  a  blunt  instrument  on  the  stomach 


THE  STENOSES  105 

end  of  the  growth  where  it  converges  into  normal 
stomach  musculature. 

By  working  through  to  the  muscularis  at  this  point 
with  a  blunt  instrument  a  line  of  cleavage  is  easily 
obtained,  and  the  tumour  can  be  readily  split  down 
to  the  duodenal  end  without  any  danger  of  punc- 
turing the  mucosa.  A  knife  should  never  be  used 
for  the  purpose,  as  it  accounts  for  many  deaths  due 
to  perforation  of  the  mucosa  when  the  Rammstedt 
technique  is  employed. 

The  edges  of  the  split  tumour  are  now  grasped  with 
the  thumb  and  index  finger  and  spread  apart.  This 
causes  the  mucosa  to  separate  from  the  muscularis, 
and  also  separates  the  few  remaining  fibres  near  the 
duodenal  end.  This  does  away  with  the  dangerous 
habit  of  attempting  to  divide  the  muscle  fibres  near 
the  duodenum  with  the  scalpel.  Having  established 
a  line  of  cleavage  from  the  separated  mucosa,  the 
mucosa  is  shelled  out,  beginning  at  the  stomach  end 
of  the  tumour.  This  unfolds  the  infolding  mucosa, 
and  also  separates  Meissner's  from  Auerbach's  plexus, 
which  is  the  first  abnormal  condition  relieved. 

The  second  step  is  to  utilise  the  hypertrophied 
muscle  tumour,  which  is  done  by  splitting  the  inner 
portion  of  the  tumour  and  using  it  as  a  flap.  This  is 
turned  out  and  sutured  over  the  shelled-out  mucosa 
with  three  interrupted  sutures,  thus  making  a 
normal  pylorus.  The  free  end  of  the  attached 
omentum  is  now  sutured  over  the  operated  area  to 
cover  the  raw  surface.  This  prevents  leakage  and 
haemorrhage,  and  at  the  same  time  gives  a  new 
vascular  supply  to  the  split  muscle  fibres. 


106  SUBGICAL  TREATMENT 

In  Strauss'  hands  the  procedure  has  given  a 
mortality  of  less  than  3  per  cent.,  while  Rammstedt's 
technique  gives  a  mortality  varying  from  15  to  30 
per  cent.  This  high  death-rate  is  due  to  two  impor- 
tant factors :  either  incomplete  division  of  the 
tumour,  of  which  Downes  and  Lewisohn  have 
reported  instances,  or  puncturing  the  mucosa  in 
attempting  to  divide  these  fibres  near  the  duodenal 
end  of  the  tumour. 

Stenoses  from  Bands  or  Adhesions 

Stenoses  occasioned  by  bands  and  adhesions  are 
infinitely  less  frequent  than  cicatricial  stenoses.  Not 
much  attention  has  been  given  them,  so  that  the 
indications  for  surgical  interference  for  their  relief 
have  given  rise  to  very  little  discussion.  Most 
writers  do  not  separate  them  from  cicatricial  fibrous 
stenoses ;  nevertheless,  we  consider  that  such  a 
distinction  is  useful. 

In  the  majority  of  cases  the  bands  are  the  conse- 
quence of  an  old  inflammatory  process  either  seated  at 
the  pylorus  or  on  the  first  portion  of  the  duodenum. 
According  to  most  writers,  they  are  the  remains  of  a 
healed  ulcer.  They  are  also  regarded  as  a  cicatricial 
phenomenon,  and  have  been  comprised  in  the  group 
of  stenosis  from  cicatricial  contraction.  In  fact,  in 
numerous  cases  the  stenosis  is  produced  by  cicatri- 
cial contraction  of  the  walls,  the  adhesions  resulting 
from  peripyloritis  only  playing  a  secondary  part. 
The  cicatrix  is  all -important,  and  it  is  this  that  must 
be  dealt  with.  There,  nevertheless,  remains  a  certain 
percentage  of  cases  in  which  the  ulcer  has  healed 


THE  STENOSES  107 

completely  and  leaves  as  a  trace  of  its  former  tran- 
sitory presence  a  band  of  adhesion,  which,  according 
to  its  site,  will  in  itself  produce  serious  disturbance. 

These  are  the  cases  that  now  interest  us.  Asso- 
ciated with  those  in  which  the  adhesions  come  from 
the  gall  bladder — which  are  the  most  frequent — or 
from  other  adjacent  viscera,  they  form  a  distinct 
group  which  should  be  closely  studied,  because  this 
group  presents  special  characters  both  in  regard  to 
symptomatology  and  therapeutical  indications. 

The  origin  and  nature  of  these  bands  are  multiple. 
Invariably  the  outcome  of  irritative  processes,  they 
may  be  given  off  from  the  various  viscera  adjacent 
to  the  pylorus  and  first  portion  of  the  duodenum. 
Adhesions  seated  on  the  greater  and  lesser  curvatures, 
and  on  the  anterior  and  posterior  surfaces  of  the 
stomach,  do  not  in  themselves  produce  stenosis.  The 
cases  of  bilocular  stomach  due  to  bands  are  infinitely 
rare — in  fact,  we  do  not  know  of  a  single  authentic 
example — and  from  this  fact  we  shall  not  consider 
them. 

Besides  the  stomach  and  duodenum,  the  organs 
which  may  be  the  origin  of  the  adhesions  are : — 

The  liver. 

The  gall  bladder. 

The  transverse  colon. 

The  kidney. 

The  pancreas. 

Bands  coming  from  the  Liver  and  Gall  Bladder. — 
Petersen  was  the  first,  we  believe,  who  especially 
studied  the  action  of  adhesions  coming  from  the 
gall  bladder,  the  remains  of  former  cholecystitis  or 


108  SURGICAL  TREATMENT 

pericholecystitis.  He  admits  that  this  is  the  most 
frequent  source  of  stenosing  bands,  a  fact  readily 
explained,  given  the  close  proximity  of  the  pylorus 
to  the  gall  bladder,  as  well  as  the  relative  frequency 
of  chronic  cholecystitis  evolving  without  apparent 
symptoms. 

These  bands  may  act  in  two  different  ways,  either 
by  merely  compressing  the  pylorus — circular  bands 
— or  by  drawing  the  pylorus  and  first  portion  of  the 
duodenum  in  the  direction  of  the  hilus  of  the  liver ; 
the  stricture  is  then  produced  by  a  bend  or  kink  of 
the  intestine.  Each  of  these  conditions  presents 
different  anatomical  states,  which  must  be  taken  into 
consideration  when  selecting  the  operative  procedure, 
as  we  shall  show. 

Transverse  Colon. — Stenoses  from  adhesions  derived 
from  the  transverse  colon  are  infinitely  rarer.  They 
are  caused  either  by  a  very  small  ulcer,  frequently 
overlooked,  or,  what  is  more  frequent,  by  colitis  and 
chronic  pericolitis,  which  are  so  frequently  found  at 
autopsy  at  the  angle  of  the  ascending  and  transverse 
colon.  In  some  cases,  although,  we  repeat,  very  rarely, 
the  adhesions  resulting  from  pericolitis  may  extend  as 
far  as  the  pylorus,  causing  a  more  or  less  marked 
degree  of  stenosis. 

Movable  Kidney. — A  movable  kidney  may  by 
mechanical  irritation  give  rise  to  adhesions  which 
are  sufficiently  extensive  to  produce  duodenal  or 
pyloric  stenosis. 

Pancreas. — From  its  anatomical  relationships  the 
pancreas  is  the  most  apt  organ  for  contracting 
adhesions  with  the  pylorus.  In  fact,  in  40  per  cent. 


THE  STENOSES  109 

of  cases  of  adhesive  perigastritis  the  adhesions  bind 
the  stomach  to  the  pancreas.  However,  it  can  be 
said  that  pyloric  stenosis  is  rarely  occasioned  by  a 
band  connecting  it  with  the  pancreas.  On  the  con- 
trary, most  of  these  adhesions  are  only  the  conse- 
quence and  complement  of  a  gastric  ulcer  or  a  pre- 
pyloric  ulcer  of  the  posterior  aspect  which  frequently 
penetrates  an  adjacent  viscus.  In  these  circum- 
stances the  stenosis  is  formed  by  the  indurated  ulcer 
possessing  a  very  marked  inflammatory  reaction,  and 
not  by  the  adhesions,  which  are,  in  this  case,  merely 
accessory. 

Adhesions  starting  from  the  pancreas  may,  never- 
theless, be  the  sole  cause  of  pyloric  stenosis,  in  which 
case  they  are  the  remains  of  an  old  pancreatitis  which 
has  extended  to  the  gastric  walls.  Such  instances 
are  rare,  but  it  is  probable  that  as  more  advance  is 
made  in  the  surgical  pathology  of  the  pancreas  the 
number  of  such  cases  will  increase. 

Because  too  little  attention  has  been  given  to  these 
adhesions,  it  is  impossible  to  offer  a  description  or  to 
formulate  any  practical  conclusion  from  the  view- 
point of  treatment.  Therefore  they  are  to  be  dealt 
with  like  cicatricial  stenoses  in  general. 

In  his  study  on  the  surgery  of  the  pancreas  Villard 
refers  to  abscesses  of  the  head  of  the  gland  which 
opened  into  the  stomach  or  intestine.  These  facts 
prove  the  possibility  of  adhesions  which  by  contrac- 
tion may  produce  stenosis. 

These  stenoses  from  bands  offer  less  distinct 
indications  for  surgical  interference  than  those  due 
to  cicatricial  contraction.  Very  variable  in  degree, 


110  SURGICAL  TREATMENT 

the  pyloric  syndrome  is  frequently  less  marked,  and 
often  transitory,  so  that  the  diagnosis  is  not  clear. 
Pain  is  the  most  prominent  symptom  of  this  con- 
dition, and  differs  from  that  complained  of  in  simple 
stasis  :  it  is  sharper,  more  acute,  and  is  more  prone  to 
occur  at  the  time  the  stomach  rids  itself  of  its  contents. 

The  diagnosis  is  made  still  more  difficult  from  the 
fact  that  in  most  instances  the  gastric  chemism  does 
not  present  any  notable  change.  But,  on  the  other 
hand,  the  patient's  antecedents  will  often  give 
valuable  data.  An  old  calculous  cholecystitis,  for 
example,  will  quickly  draw  the  physician's  attention, 
therefore  aiding  in  the  diagnosis.  In  other  cases  it 
will  be  quite  different.  No  history  of  any  definite 
affection  will  be  ascertained ;  all  that  the  patient 
will  complain  of  will  be  some  indefinite  pain  recurring 
at  regular  intervals  without  distinct  character.  By 
deep  palpation  in  the  epigastric  area  only  vague, 
indefinite  pain  will  be  elicited,  altogether  insufficient 
for  diagnostic  purposes. 

When,  into  the  bargain,  the  patient  is  emaciated 
and  exhausted,  with  appetite  and  animation  gone, 
there  is  little  else  necessary  for  regarding  the  case  as 
one  of  neurasthenia,  and  this  is  the  diagnosis  that 
comes  to  the  mind  of  many,  who  are  content  with  it 
and  do  not  search  further.  A  treatment  in  which 
psychotherapy  is  given  free  measure  is  started,  much 
to  the  detriment  of  the  patient. 

Naturally,  under  the  influence  of  rest  and  sugges- 
tion, an  amelioration  is  soon  wrought,  but  this 
improvement  is  deceptive  because  it  is  temporary  ; 
it  is  sufficient  to  confirm  the  diagnostic  simplism  at 


THE  STENOSES  111 

first  adopted,  and  which  will  be  maintained  in  spite 
of  evident  error,  which  only  too  often  will  appear 
when  it  is  too  late. 

Therefore  it  is  only  by  a  close  study  of  the  patient, 
and,  above  all,  by  repeated  examinations,  without 
preconceived  ideas,  by  means  of  special  research 
which  may  give  precise  data  as  to  the  functions  of 
the  stomach  and  pancreas,  that  a  diagnosis  can  be 
made.  When  these  various  examinations  shall  have 
failed  to  reveal  the  existence  of  any  anatomical 
lesion,  gastric  asthenia  of  purely  nervous  origin  may 
be  considered  exact,  and  rational  treatment  insti- 
tuted. However,  in  the  majority  of  cases  careful 
examination  will  at  length  reveal  some  anatomical 
lesion,  and  from  this  fact  surgical  measures  will 
become  indicated.  Medical  treatment  can  accom- 
plish nothing,  excepting,  perhaps,  to  bring  about  an 
apparent  and  temporary  cure,  while  surgical  treat- 
ment will  be  sovereign  and  should  be  proposed  as 
soon  as  the  diagnosis  has  been  made  on  a  firm  basis. 
In  doubtful  cases  exploratory  laparotomy  may 
render  great  service.  There  is  certainly  less  risk  in 
an  exploratory  incision  than  to  lose  time  in  coquetting 
with  medical  treatment  that  only  too  often  is  illusive. 
The  procedure  selected  will  vary  greatly  according 
to  circumstances,  and  we  have  a  choice  of  several 
methods  which  have  each  their  special  indications. 
The  principal  are  : — 

Gastrolysis. 

Duodenostomy. 

Gastroenterostomy. 

Kesection. 


112  SURGICAL  TREATMENT 

Gastrolysis,  the  simplest  of  all  gastric  operations, 
may  in  the  circumstances  give  good  results.  The  mere 
division  of  a  band  when  this  is  stout  and  narrow  may 
result  in  a  permanent  cure.  It  is  advantageous  from 
its  very  simplicity,  making  it  a  benign  interference. 

When  the  adhesions  are  thick,  forming  a  fibrous 
cuff  around  the  pylorus  and  extending  to  the  liver 
and  pancreas,  the  operation  becomes  infinitely  more 
complicated.  Moreover,  the  resected  bands  leave 
raw  surfaces,  which  will  give  rise  to  new  adhesions 
with  great  rapidity.  Therefore  peritoneoplasty  must 
be  done,  a  thing  not  always  possible,  particularly 
when  the  base  of  implantation  is  very  extensive.  In 
these  circumstances  the  omentum  should  be  used  for 
covering  the  raw  areas.  The  adhesions  will  then 
develop  on  a  particularly  movable  organ,  and  not  on 
a  fixed  viscus.  The  dragging  resulting  from  the 
peristaltic  movements  of  the  stomach  will  not  be 
painful. 

Moreover,  when  the  stenosis  has  existed  for  some 
time,  often  quite  long,  the  gastric  mucosa  and 
muscularis  are  the  seat  of  chronic  inflammation  which 
has  caused  sclerous  degeneration  of  the  tissues. 
Consequently  the  fear  of  recurrence  and  fibrous 
stenosis  of  the  pylorus  itself  is  why  simple  gastrolysis 
is  rarely  employed.  It  can  only  be  indicated  in  cases 
where  a  narrow  band  forms  a  cord  constricting  a 
pliant,  flexible  pylorus,  which  will  assume  its  normal 
shape  when  the  band  has  been  divided. 

In  the  majority  of  cases  most  operators  prefer 
making  a  gastric  stoma.  Therefore  gastroenteros- 
tomy  is  more  frequently  done,  or  gastroduodenos- 


THE  STENOSES  113 

tomy,  which,  in  some  cases,  is  very  distinctly 
indicated.  We  have  sufficiently  studied  the  advan- 
tages and  disadvantages  of  gastroenterostomy,  which 
are  the  same  in  these  types  as  in  other  types  of  pyloric 
stenosis. 

As  to  gastroduodenostomy,  we  have  already 
referred  to  its  many  advantages,  but  its  great  defect 
is  that  it  requires  particularly  favourable  anatomical 
conditions  for  its  execution,  and  these  are  rarely 
present.  But  these  conditions  are  precisely  found 
united  in  some  cases  of  stenosis  from  adhesions. 
Thus  adhesions  resulting  from  cholecystitis,  dragging 
the  pylorus  upward  and  backward,  produce  a  stenosis 
from  kinking  rather  than  a  true  stricture.  In  these 
circumstances  the  prepyloric  portion  and  the  first 
portion  of  the  duodenum  are  in  contact,  and  an 
anastomosis  can  be  made  between  them  without 
much  risk  of  too  much  dragging,  as  is  usually  the  case. 
This  has  been  carried  out  successfully  by  Villard. 

Therefore  it  can  be  said  that,  according  to  circum- 
stances, a  simple  gastrolysis,  followed  by  peri- 
tonisation,  may  be  done — in  cases  of  unimportant 
isolated  adhesions — or  gastroduodenostomy  when  the 
band  is  situated  in  such  a  way  that  it  brings  the 
duodenum  in  contact  with  the  stomach.  Finally, 
in  all  cases  gastroenterostomy  will  give  good  results, 
combined  or  not  with  gastrolysis,  according  to  the 
position  and  importance  of  the  adhesions. 

The  results  of  these  various  operations  are  similar 
to  those  for  cicatricial  stenosis,  that  is  to  say, 
excellent.  We  would  merely  add — we  cannot  insist 
upon  this  too  frequently — that  the  bad  results  and 


S.T. 


114  SUEGICAL  TREATMENT 

partial  failures  are  for  the  most  part  due  to  long 
delays  before  resorting  to  surgical  treatment.  From 
the  fact  that  these  patients  are  treated  as  neuras- 
thenics they  finally  become  neurasthenic,  and  it  often 
requires  a  long  time  to  convince  them  that  they 
are  not. 

Mediogastric    Stenosis 

Mediogastric  stenosis  represents  bilocular  or  hour- 
glass stomach,  a  relatively  rare  condition  when  com- 
pared to  pyloric  stenosis.  It  is  for  this  reason  that 
less  attention  has  been  given  to  the  treatment  of  this 
condition,  while  the  results  are  not  sufficiently 
numerous  to  enable  us  to  estimate  the  special  indica- 
tions for  operation  and  the  choice  of  the  procedure  to 
be  selected.  Moreover,  the  respective  advantages  of 
various  procedures,  above  all  depend  upon  eminently 
variable  anatomical  circumstances,  much  more  so 
than  in  stenosis  purely  pyloric. 

Bilocular  stomach  can  only  result  from  contraction 
of  the  gastric  wall  of  such  importance  that  it  must  be 
the  consequence  of  a  callous  ulcer  having  contracted 
important  adhesions  with  the  adjacent  viscera  or 
even  invading  them.  Operation  will  here  be  very 
delicate  on  account  of  the  bad  condition  of  the 
tissues  and  the  slight  mobility  of  the  organ.  It  will 
also  generally  be  an  important  interference.  The 
various  procedures  that  have  been  employed  are : — 

Gastroplasty. 

Gastroanastomosis. 

Simple  gastro-enteroanastomosis. 

Double  gastro-enteroanastomosis 

Annular  resection. 


THE  STENOSES  115 

It  is,  we  repeat,  impossible  to  compare  the  results 
obtained  by  these  various  procedures  in  order  to 
form  an  idea  of  the  best  method  to  select.  The 
advantages  of  any  of  them  essentially  depend  upon 
the  type  of  stenosis,  and,  on  the  other  hand,  the  cases 
met  with  are  not  comparable.  Naturally  some  of 
them  rest  upon  general  principles  which  will  cause 
them  to  be  at  once  rejected  or  accepted,  but  several 
depend  upon  indications  that  are  dictated  only  by 
anatomical  circumstances. 

Gastroplasty,  analogous  to  pyroplasty,  offers  the 
same  advantages  and  disadvantages  as  the  latter 
operation.  The  disadvantages  are  even  more  marked 
given  the  greater  infrequency  of  a  soft  cicatrix  result- 
ing in  biloculation.  Moreover,  the  communication 
between  the  two  gastric  pouches  must  be  made  much 
larger  than  in  plastic  operations  on  the  pylorus. 

As  to  the  immediate  functional  results,  and 
especially  the  remote  results,  the  cases  operated  on 
by  this  procedure  are  so  rare  that  even  an  approxi- 
mate idea  cannot  be  formed  as  far  as  frequency  of 
recurrence  is  concerned. 

Gastroanastomosis  may  be  compared  to  gastro- 
duodenostomy.  It  presents  the  same  advantages 
as  well  as  the  weak  points.  An  ideal  operation  from 
the  fact  that  it  simply  re-establishes  the  onward 
transit  of  the  gastric  contents,  it  has  one  disad- 
vantage :  it  can  rarely  be  done.  The  indurated 
tissues  and  contracted  adhesions  prevent  the  neces- 
sary approximation  of  the  two  pouches.  Neverthe- 
less the  anatomical  conditions  lend  themselves  more 
frequently  to  this  operation  than  they  do  to  a  simple 

I  2 


116  SURGICAL  TREATMENT 

plastic  operation,  while  the  results  appear  to  be  quite 
as  favourable.  Watson,  who  advocated  this  method, 
declared  that  it  had  given  him  excellent  results,  but 
cases  operated  on  by  other  surgeons  are  few  in 
number  and  not  conclusive. 

Gastroenterostomy,  as  in  other  purely  pyloric 
stenoses,  is  decidedly  indicated.  It  offers  the  same 
advantages  in  that  it  can  be  done  in  all  cases  and 
that  it  is  both  simple  and  devoid  of  danger.  Theo- 
retically it  might,  perhaps,  be  said  that  it  is  inferior 
to  gastroplasty  and  gastroanastomosis,  since  it  not 
only  excludes  the  duodenum,  but  a  part  of  the 
stomach  as  well.  It,  therefore,  decreases  the  gastric 
preparation  of  food  to  a  considerable  degree  before 
it  is  transferred  to  the  jejunum,  but  in  practice  the 
results  obtained  by  it  are  none  the  less  good,  and  it 
may  be  said  that  gastroenterostomy  can  advan- 
tageously take  the  place  of  other  procedures  in 
mediogastric  stenoses. 

In  bilocular  stomachs  simple  gastroenterostomy 
usually  suffices,  but  it  may  happen  that,  following 
multiple  ulcers,  the  stomach  may  present  two 
stenoses :  a  mediogastric  and  a  pyloric  stenosis.  In 
these  circumstances  it  is  natural  that  the  secretions 
cannot  be  allowed  to  sojourn  in  the  pyloric  pouch,  and 
that  their  evacuation  must  also  be  attended  to.  The 
simplest  means  is  to  make  an  anastomosis  on  each  of 
the  pouches,  thus  giving  each  one  its  own  outlet. 
Clement  has  recommended  this  operation;  and  his 
example  has  been  followed  by  others,  among  them 
Monprofit. 

Consequently,  among  the  simply  palliative  opera- 


THE  STENOSES  117 

tions,  gasiroenterostomy,  either  single  or  double, 
gives  the  surest  results  ;  it  is,  at  the  same  time,  the 
simplest  and  usually  the  most  rapid  method. 

As  to  resections,  the  application  of  partial  atypical 
excisions  is  hardly  possible  to  the  conditions ;  and,  for 
that  matter,  they  have  only  given  mediocre  results. 

On  the  other  hand,  annular  resection  has  been 
quite  specially  studied.  Leriche  warmly  advocates 
it,  and  reports  several  operated  cases  which  are  really 
encouraging.  Nevertheless,  in  spite  of  this  fortu- 
nate series,  annular  resection  is  dangerous.  It  is  a  far 
more  serious  interference  than  the  others  we  have  con- 
sidered. It  can  be  undertaken  when  the  anatomical 
conditions  are  particularly  favourable,  especially 
when  the  patient  is  in  good  general  condition,  but 
in  all  cases  in  wilich  the  state  of  physical  exhaustion 
is  such  that  a  long  and  laborious  procedure  is  contra- 
indicated,  preference  should  unquestionably  be  given 
to  gastroenterostomy,  which  will  assure  just  as  good 
ultimate  results. 

Annular  resection,  like  pylorectomy,  is  to  be  recom- 
mended when  it  can  be  easily  carried  out,  and  when 
the  tissues,  after  excision  of  the  cicatricial  portion, 
are  sufficiently  pliant  and  solid  for  secure  suturing, 
otherwise  it  is  to  be  rejected  in  every  case  in  which 
the  circumstances  are  not  absolutely  favourable. 

The  risk  and  danger  to  which  this  operation 
exposes  the  patient  being  considered,  the  advantages 
it  offers  are,  all  things  being  equal,  insufficient  for  it 
to  be  preferred  to  palliative  procedures. 


CHAPTER  VI 

GASTRIC     ULCER  :     ITS     ETIOLOGY,    PATHOGENESIS, 
PATHOLOGY   AND   CLINICAL   TYPES 

THE  more  the  indications  for  operation  are  simple 
and  little  discussed  for  pyloric  stenosis,  the  more 
complex  they  become  in  cases  of  ulcer  in  activity. 
We  know  that  gastric  ulcer  is  unquestionably  more 
serious  than  duodenal  ulcer.  Surgical  interference 
for  its  relief  is  surrounded  by  greater  gravity,  but 
this  is  largely  due  to  the  inferior  state  of  health 
usually  present  in  ulcer  subjects.  Moynihan  has 
recently  stated  that  "  recoveries  after  operation  are 
fewer  whatever  the  nature  of  the  operation,  and  the 
rate  of  mortality  of  the  patients  in  the  years  subse- 
quent to  operation,  as  Balfour  has  recently  shown, 
...  is  three  times  as  high  as  in  patients  operated  on 
for  duodenal  ulcer." 

Gastric  ulcer  is  said  to  be  a  relatively  infrequent 
process,  being  but  a  fraction  of  1  per  cent,  of  the 
findings  at  general  necropsies  (C.  H.  Mayo).  Brinton, 
Fenwick  and  Lebert  believe  that  gastric  ulcer  is  to 
be  met  with  in  an  average  of  4  per  cent,  to  5  per  cent., 
while  other  writers  place  the  average  at  from  0-6  to 
0-8  per  cent.  This  gross  difference  may  be  explained 
by  the  fact  that  the  former  observers  based  their 
researches  on  autopsy  diagnosis — open  or  cicatrised 
ulcers — while  the  latter  have  worked  out  an  average 


GASTRIC  ULCER  119 

founded  on  clinical  data.  It  is  therefore  manifest 
that  a  large  proportion  of  gastric  ulcers  undergo 
their  evolution  without  giving  any  sign  of  their 
presence  and  are  so  torpid  that  they  are  not  even 
suspected  by  the  patient.  In  spite  of  this  silent 
evolution,  they  nevertheless  may  give  rise  to  serious 
remote  disturbances.  Hence  adhesions  due  to  latent 
ulcer  may  produce  such  vague  remote  symptoms 
that  it  is  out  of  the  question  to  make  a  certain  and 
exact  diagnosis  from  the  very  fact  that  no  trace 
remains  of  the  primary  process,  the  real  cause  of  a 
considerable  number  of  dyspepsias  with  ill-defined 
characters.  And,  what  is  more,  cases  are  not  so  rare 
in  which  the  first  evidence  of  ulcer  is  perforation,  not 
a  perforation  due  to  an  acute  ulcer  with  rapid  evolu- 
tion, but  a  chronic  ulcer  with  sclerous  edges  and 
surrounded  by  a  broad  area  of  callous  tissue  testifying 
to  the  long  standing  of  the  lesion.  We  have  not 
infrequently  met  with  cases  of  perigastric  bands 
which  certainly  were  the  result  of  a  former  ulcer,  but 
whose  existence  could  not  even  be  suspected  from  the 
patient's  anamnesis. 

In  the  space  of  five  years,  of  the  gastric  ulcer  cases 
at  the  Mayo  clinic,  the  lesion  was  located  on  or 
around  the  lesser  curvature  534  times,  eighty-five 
involved  the  posterior  wall,  the  greater  curvature  in 
nine,  while  the  anterior  wall  was  the  seat  of  the  lesion 
in  five.  The  exact  site  was  not  definitely  recorded 
in  five.  Of  those  on  the  posterior  wall  8-2  per  cent, 
were  in  the  pyloric  third,  73-3  per  cent,  in  the  middle 
third,  and  16-5  per  cent,  in  the  cardiac  end. 

Sex. — It  is  usually  admitted  that  gastric  ulcer  is 


120  SURGICAL  TREATMENT 

more  common  in  women  than  in  men,  the  ratio  being 
3:1.  We  merely  make  this  remark  without  attach- 
ing importance  to  it,  because  if  one  envisages  the 
cases  of  serious,  rebellious  or  complicated  ulcers — 
ulcers  that  may  be  called  surgical — the  proportion 
becomes  reversed.  The  majority  of  writers  refer  to 
this  difference  of  character  of  the  lesion  according  to 
the  sex  of  the  patient.  If  an  explanation  for  this 
difference  be  searched  for,  it  must  be  admitted  that 
it  is  principally  due  to  the  fact  that  women  generally 
follow  medical  treatment  better,  that  they  are  much 
less  inclined  to  digression  in  eating,  and  that,  above 
all,  they  use  alcohol  to  a  far  lesser  extent,  particularly 
spirits.  We  can  confirm  Soupault's  belief  when  he 
says  that  hygiene  in  general  and  alimentary  hygiene 
in  particular  have  little  influence  in  the  production  of 
gastric  ulcer,  but  that,  on  the  other  hand,  this  influ- 
ence makes  itself  unquestionably  felt  on  the  evolution 
of  the  lesion  on  account  of  the  congestion  and  inflam- 
mation of  the  gastric  mucosa  that  this  defective 
hygiene  keeps  up.  For  these  reasons  operation  statis- 
tics give  more  males  than  females,  the  average  ratio 
being  about  2:1.  A  point  that  should  likewise  be 
made,  one  that  has  been  particularly  studied  by 
Mathieu,  is  that  the  ulcer  is  much  more  frequent  in 
some  countries  than  in  others.  Whether  or  not  the 
mode  of  life  has  anything  to  do  with  it  is  a  question, 
and  if  one  carefully  examines  the  details  of  operations 
done  at  various  clinics  it  is  at  once  striking  how  some 
surgeons  meet  with  infinitely  more  serious  cases,  with 
more  extensive  and  deep  lesions,  than  others.  Is 
this,  perhaps,  due  to  a  better  clinical  appreciation  of 


GASTEIC  ULCER  121 

the  cases  ?  We  are  not  inclined  to  think  so,  and 
believe  that  certain  regions  are  singularised  by  the 
fact  of  a  greater  frequency  of  ulcer,  while  others  have 
the  unenviable  reputation  of  exceptionally  serious 
cases  of  ulcer. 

Pathogenesis 

The  pathogenesis  of  ulcer  of  the  stomach  is  still 
moot ;  the  hypotheses  explaining  its  development 
and  formation  are  still  numerous,  too  numerous 
even  to  admit  that  the  problem  is  solved.  Many 
researches  have  been  carried  out,  and  these,  both 
experimental  and  clinical,  have  remained  sterile, 
nobody  having  been  able  to  confirm  the  real  value  of 
any  one  of  the  theories  so  far  proposed.  As  Soupault 
justly  remarks,  the  problem  will  remain  unsolved  as 
long  as  a  typical  gastric  ulcer,  both  from  the  patho- 
logical and  clinical  view -points,  shall  not  have  been 
experimentally  reproduced.  More  and  more  it  is 
being  admitted  that  the  ulcer  does  not  depend  upon 
a  single  etiological  factor,  but  that  it  is  produced  by 
various  circumstances  which  act  only  when  asso- 
ciated. Therefore,  if  we  cannot  accept  as  exact 
the  many  hypotheses  successively  propounded,  we 
should,  nevertheless,  admit  that  each  one  of  these 
factors  may  play  a  more  or  less  important  part  in 
the  production  of  the  ulcer  and  in  its  evolution.  For 
this  reason  we  esteem  it  not  devoid  of  interest  to 
review  these  causes  briefly. 

The  Theories  of  the  Pathogenesis  of  Ulcer.  — 
Virchow  admitted  that  gastric  ulcer  was  due  to 
the  occlusion  of  one  of  the  gastric  arteries  from 


122  SUKGICAL  TREATMENT 

embolus,  with  the  result  that  an  area  of  necrobiosis 
ensued.  Some  clinical  data  would  seem  to  bear  out 
this  supposition.  Thus  Lebert,  in  1852,  detected 
arterial  emboli  in  the  neighbourhood  of  the  ulcer  ; 
Godiner  reported  a  case  of  duodenal  ulcer  due  to  an 
embolus  in  the  pancreatico-duodenal  artery.  Lebert 
even  carried  out  what  he  assumed  to  be  conclusive 
experiments  on  this  subject,  but  Cohnheim  demon- 
strated that  the  gastric  arteries  anastomosed  suffi- 
ciently for  it  to  be  impossible  for  an  embolus  to 
produce  a  sufficiently  intense  local  anaemia  to  bring 
about  necrobiosis  and  ulceration. 

Other  observers  have  suspected  that  arterial 
thrombosis  was  the  cause  of  the  ulcer,  but  they  have 
been  unable  to  advance  any  anatomical  proof  in 
support  of  their  hypothesis.  We  must,  however, 
acknowledge  that,  although  a  thrombosis  may  not 
appear  to  be  the  initial  cause  of  the  lesion,  it  may 
aid  in  its  extension.  In  fact,  thrombosed  vessels  are 
to  be  found  in  the  neighbourhood  and  in  the  limits 
of  the  ulcer.  These  thromboses  are  certainly  the 
consequence,  and  not  the  cause,  of  the  periulcerous 
inflammation,  but  from  the  disturbances  in  the  local 
circulation  to  which  they  give  rise  they  are  an 
important  factor  in  the  surface  extension  and 
penetration  in  depth  of  the  lesion. 

Still  others,  wishing  to  explain  the  pathogenesis  of 
gastric  ulcer  by  local  circulatory  disturbances,  main- 
tain that  neither  thrombosis  nor  embolus  should  be 
incriminated,  but  in  reality  spasmodic  contraction 
of  the  arteries  should  be  regarded  as  the  etiological 
factor.  As  Soupault  points  out,  this  hypothesis  is 


GASTRIC  ULCER  123 

"  entirely  gratuitous   and   rests    upon   no  founda- 
tion." 

Rokitansky,  Rindfleisch  and  Axel-Key,  rejecting 
the  theories  which  suppose  arterial  circulatory  dis- 
turbances, accuse  venous  changes  as  the  cause  of 
ulcer.  Venous  thrombosis,  from  the  stasis  it  brings 
about,  favours  interstitial  haemorrhage  and  infiltra- 
tion of  the  mucosa  and  submucosa ;  hence  is  produced 
an  area  of  lessened  resistance,  the  starting-point  of  the 
lesion. 

Some  cases  have  been  reported,  although  very  few 
in  number,  of  gastric  ulcer  due  to  traumata,  involving 
the  epigastric  region  or  the  gastric  mucosa  directly, 
and  Fuld  has  reported  an  example.  Several  of  these 
cases  are  evident,  and  do  not  admit  of  denying  the 
influence  of  trauma.  Nevertheless  trauma  cannot 
be  considered  otherwise  than  an  adjuvant  factor, 
and  not  the  primordial  cause  of  the  ulcer. 

Letulle  was  the  promoter  of  theories  based  upon 
infection.  He  reports  several  clinical  cases  which 
led  him  to  adopt  this  theory,  and  he  has  also  been  able 
to  experimentally  produce  gastric  lesions  which 
closely  resemble  simple  ulcer  by  injecting  bacteria 
into  the  vessels  of  the  stomach.  Chantemesse  carried 
out  similar  experiments,  and  came  to  the  same  con- 
clusions. Nevertheless  the  majority  of  observers 
regard  these  lesions  of  the  mucosa  as  simple  ulcerative 
processes,  and  not  true  round  ulcers  which  have  a 
very  different  evolution. 

It  is  known  that  bacterial  toxins  may  occasionally 
produce  serious  gastric  ulcers.  Some  writers  have 
built  up  a  theory  based  on  this  fact,  attributing  a 


124  SUEGICAL  TREATMENT 

toxaemic  origin  to  the  lesion.  It  is  certainly  possible 
that  an  ulcer  thus  formed  may  pass  on  to  the  chronic 
stage  if  death  does  not  ensue  from  the  infectious 
disease,  the  origin  of  the  toxaemia,  but  such  instances 
are  too  rare  for  one  to  accept  this  point  of  view  and 
to  raise  it  to  the  level  of  a  general  theory. 

Pavy  regarded  gastric  ulcer  as  simply  a  manifesta- 
tion of  altered  general  health  and  change  in  the 
composition  of  the  blood,  especially  a  decrease  of 
its  alkalinity.  For  Quincke  and  Dettwyler  this 
condition  is  one  of  simple  anaemia,  and  Silbermann 
maintained  that  it  was  haemoglobin asmia.  These 
general  causes  may  undoubtedly  have  an  influence 
even  considerable,  but  they  can  only  be  of  secondary 
importance  at  the  most. 

Lastly,  certain  observers,  discarding  those  theories 
which  search  for  the  cause  of  ulcer  in  circulatory  dis- 
turbances or  in  general  conditions  which  can  at  the 
best  only  play  an  inconspicuous  part,  have  attributed 
capital  importance  to  the  gastric  secretions  in  the 
production  of  the  lesion  under  discussion.  The  action 
of  the  gastric  juice  has  an  undeniable  importance,  but 
the  changes  in  chemism  show  that  cases  of  gastric 
hyperactivity  without  any  symptom  of  ulcer  are  far 
too  numerous  for  the  theory  of  simple  autodigestion 
to  be  acceptable  in  its  entirety  and  its  exclusivism. 

Hence  was  born  the  more  complex  conception  that 
is  at  present  entertained  of  the  pathogenesis  of  ulcer, 
and  which,  in  fact,  acknowledges  the  capital  part 
played  by  autodigestion.  Nearly  all  recent  writers 
regard  this  theory  as  the  one  coming  nearest  to  the 
truth,  and  which  is  founded  on  well-studied  positive 


GASTRIC  ULCER  125 

data.  The  principal  arguments  which  plead  in  its 
favour  are  : — 

Round  ulcer  is  only  met  with  at  those  parts  of  the 
digestive  tube  which  are  in  contact  with  the  gastric 
juice.  The  lesion  is  found  at  the  lower  end  of  the 
oesophagus,  in  the  stomach,  duodenum  and  first 
portion  of  the  jejunum,  in  patients  who  have  under- 
gone gastroenterostomy.  Moreover,  the  ulcer  is 
localised  preferably  at  those  areas  where  the  activity 
of  the  gastric  secretion  is  most  distinctly  felt.  Very 
uncommon  at  the  oesophagus,  where  it  can  only  be 
produced  by  the  rather  infrequent  regurgitations,  it 
becomes  more  frequent  at  the  fundus  and  body  of  the 
stomach,  but  attains  its  maximum  at  the  pylorus  and 
in  the  prepyloric  region.  Soupault,  Riedel  and  others 
maintain  that  70  per  cent,  of  ulcers  are  seated  in 
this  portion  of  the  stomach,  where  the  gastric  secre- 
tion possesses  its  maximum  activity  and  sojourns  the 
longest.  Finally,  when  the  pylorus  has  been  traversed 
ulcer  becomes  less  and  less  frequent  as  the  stomach 
becomes  more  distant.  It  is  in  the  first  10  centimetres 
of  this  intestinal  segment  that  ulcer  is  the  most 
frequent  (246  out  of  260  cases). 

We  pointed  out  when  speaking  of  peptic  ulcer  of 
the  jejunum,  a  lesion  quite  comparable  in  its  evolu- 
tion to  round  ulcer,  that  this  post-operative  com- 
plication is  met  with  only  in  the  first  portion  of  the 
jejunum,  where  the  gastric  secretion  has  not  as  yet 
been  weakened  by  the  intestinal  secretions.  Like- 
wise, as  it  has  been  recognised  for  a  long  time,  peptic 
ulcer  is  never  encountered  excepting  in  cases  operated 
on  for  non-malignant  affections  of  the  stomach. 


126  SURGICAL  TREATMENT 

Peptic  ulcer  following  gastroenterostomy  in  cases  of 
malignant  processes  of  the  stomach  is  still  unknown. 
This  would  seem  to  demonstrate  the  influence  of  the 
active  or  even  hyperactive  gastric  juice  in  the  pro- 
duction of  the  lesion  under  consideration,  since  it  has 
never  been  encountered  in  cases  where  gastric  chemism 
was  diminished,  as  in  typical  adenocarcinoma  of  the 
stomach. 

Not  only  is  the  action  of  gastric  juice  an  acknow- 
ledged cause  of  ulcer,  but  this  secretion  must  at  the 
same  time  be  hyperactive  in  order  that  the  morbid 
process  shall  assume  a  really  chronic  evolution, 
characterised  by  its  tendency  to  extend. 

All  those  who  have  carried  out  exact  researches  on 
this  point  are  unanimous  in  recognising  that  the  ulcer 
always  coincides  with  a  change  in  the  gastric  chemism, 
hyperchlorhydria  or  hypersecretion,  so  that  for  many 
this  change  is  even  one  of  the  best  diagnostic  elements 
at  our  disposal.  But,  as  is  the  case  for  all  laboratory 
examinations,  an  absolute  constancy  in  results  must 
not  be  expected.  A  number  of  instances  of  ulcer 
have  been  recorded  in  which  the  gastric  secretions 
were  normal  or  even  diminished.  Such  cases  are 
easily  explained,  as  Soupault  has  pointed  out. 
According  to  this  observer,  a  certain  number  of  cases 
of  ulcer  that  have  been  published  on  account  of  this 
peculiarity  only  presented  the  characters  of  simple 
acute  ulcer  rapidly  evolving  towards  cure. 

Another  group  of  these  cases  can  be  explained  by 
mistakes  made  in  the  examination  of  the  chemism. 
It  must  not  be  forgotten  that  gastric  chemism 
sensibly  varies  with  the  phases  of  the  affection  under 


GASTKIC   ULCEE  127 

discussion.  Thus  Bouveret  mentions  several  cases 
in  which  examination  revealed  hypochlorhydria  after 
a  more  or  less  lengthy  period  of  gastric  intolerance, 
while  it  was  distinctly  hyperchlorhydric  during  the 
periods  of  calm  and  remission. 

Soupault  likewise  points  out  that  in  cases  of  pyloric 
stenosis  a  delay  in  the  secretion  is  generally  noted, 
which  can  be  proved  by  making  two  successive 
examinations  of  the  same  individual.  The  first  one, 
made  at  the  end  of  one  hour,  will  show  normal 
chemism ;  and  it  will  only  be  the  second  examination, 
made  one  hour  and  a  half  later,  that  will  reveal  hyper- 
chlorhydria.  Now  it  is  very  rare  for  one  to  wait  so 
long  before  withdrawing  the  test  meal,  and  thus  is 
explained  the  fact  that  very  often  gross  differences 
are  overlooked. 

Finally,  other  cases  are  to  be  explained  by  the  age 
of  the  lesion.  After  a  time  the  ulcer  will  react  on  the 
gastric  mucosa  in  general,  hence  glandular  atrophy 
and  diminished  secretion.  We  have  already  referred 
to  this  impairment  of  the  gastric  functions ;  therefore 
no  further  comment  is  necessary.  We  would  merely 
mention  this  fact,  likewise  that  well-known  one  of  the 
change  of  chemism  following  malignant  transforma- 
tion of  the  ulcer. 

Therefore,  if  we  except  the  few  cases  mentioned  by 
various  writers,  and  which  are  almost  all  amenable 
to  the  explanations  given  above,  it  may  be  admitted 
in  a  general  way  that  ulcer  is  always  associated  with 
hyperchlorhydria.  There  is  certainly  a  very  intimate 
relationship  between  ulcer  and  the  glandular  hyper- 
functionating  of  the  stomach. 


128  SURGICAL  TREATMENT 

Still  other  proofs  can  be  adduced  in  support  of  this 
assertion.  Thus  we  would  point  out  the  infrequency 
of  cases  of  ulcer  simultaneously  evolving  with  gastric 
cancer  which  has  not  become  grafted  on  the  ulcer, 
although  we  are  unable  to  produce  figures  or  statis- 
tics. It  might  almost  be  said  that  one  lesion  excludes 
the  other,  and  yet,  in  cases  of  neoplasms,  several 
anatomical  causes  are  combined,  namely,  vascular 
lesions,  infection  and  anaemia,  all  of  which  are  known 
to  favour  ulcer  formation. 

But  although  everybody,  in  fact,  admits  this  close 
relationship  between  ulcer  and  hyperchlorhydria,  it 
may  be  asked  which  one  of  the  affections  causes  the 
other.  Does  the  ulcer  produce  hyperchlorhydria,  or 
does  the  latter  favour  the  development  of  the  ulcer  ? 

It  is  certain  that  ulcer  exerts  considerable  influence 
on  gastric  secretions,  that  it  excites  them  and  hence 
increases  them  in  very  notable  proportion.  Pawlow 
appears  to  have  demonstrated  this  influence  by  the 
following  experiment : — 

A  portion  of  the  stomach  was  isolated,  care  being 
taken  to  spare  its  nerve  and  vascular  supply.  This 
resulted  in  a  large  and  small  stomach,  quite  indepen- 
dent of  each  other.  In  the  small  pouch  Pawlow 
induced  an  ulcer,  while  in  the  larger  pouch  he 
made  a  fistula  in  order  to  study  the  changes  taking 
place  in  the  secretions.  By  this  means  he  was  able 
to  show  that  as  long  as  the  evolution  of  the  artificial 
ulcer  continued  the  percentage  of  acidity  increased 
in  the  secretions.  From  this  experiment  Pawlow 
concluded  that  the  ulcer  is  the  starting-point  of 
reflexes  which  stimulate  the  glandular  secretions. 


GASTEIC  ULCER  129 

Moreover,  Soupault  points  out  that  radical  surgical 
treatment  of  the  ulcer  causes  the  hyperacidity  to  drop 
until  the  normal  percentage  is  reached,  and  this 
regardless  of  the  fact  that  the  alkaline  intestinal 
secretions  flow  back  into  the  stomach  through  the 
stoma.  According  to  Mathieu,  this  would  be  in 
favour  of  the  theory  which  attributes  gastric  hyper- 
secretion  to  reflex  vasomotor  phenomena  whose 
starting-point  is  in  the  inflamed  and  irritated  ulcer. 
But  in  surgical  cases  the  lesions  are  old,  offering  a 
manifestly  chronic  character  which  cannot  be  com- 
pared with  ulcers  in  formation.  The  same  conditions 
favouring  the  development  of  the  ulcer  are  not 
present,  and  from  this  fact  this  argument  can  hardly 
be  brought  forward  in  regard  to  the  question  of  pure 
pathogenesis.  Nevertheless  Pawlow's  experiment 
shows  that  the  ulcer  plays  an  important  part  in  the 
production  of  gastric  acidity  ;  and  it  would  appear  to 
be  more  in  keeping  to  admit,  with  Mathieu,  that  the 
hypersecretion  is  anterior  to  the  ulcer,  but  that  the 
latter  maintains  it,  and  a  true  vicious  circle  is 
established. 

For  that  matter,  the  ulcer  may  act  on  the  gastric 
secretion  in  two  ways.  We  have  already  seen  that 
it  acts  directly  on  the  glandular  system  by  vasomotor 
reflex  and  nervous  reflex  as  well,  but  only  by  its 
action  on  the  exclusively  glandular  nerve  endings. 
It  may  also  act  by  provoking  pyloric  spasm,  which, 
as  Doyen,  Mikulicz,  Carle  and  Fantino  have  shown, 
sets  up  and,  above  all,  maintains  hyperchlorhydria. 
Now  pyloric  spasm  is  common  in  gastric  ulcer,  be 
the  lesion  in  the  pylorus  or  prepyloric  region,  or  even 


130  SURGICAL  TREATMENT 

remote  from  it.  It  is  also  one  of  the  causes — and 
certainly  not  the  least — of  the  chronicity  of  the  ulcer. 
By  producing  hypersecretion,  as  well  as  favouring  its 
prolonged  contact  with  the  ulcer,  spasm  is  one  of  the 
most  important  pathogenic  factors.  Its  symptoms 
are  frequently  marked,  and  render  it  apparent,  and 
it  is  probably  far  more  common  than  is  generally 
suspected.  Occasionally  also,  being  ill  denned  and 
transitory,  it  may  be  readily  overlooked,  and  still  it 
exerts  a  nefarious  influence  on  the  morbid  process. 
Perhaps  the  disappearance  of  the  spasm  might 
explain  the  decrease  of  the  gastric  secretion  observed 
by  Soupault  following  surgical  removal  of  the  ulcer, 
the  starting-point  of  the  reflex  causing  the  spasm 
having  thus  been  eliminated,  but  these  are  still 
obscure  points,  difficult  to  elucidate. 

However,  whether  it  is  by  vasomotor  reflex, 
directly  neuro-glandular  in  nature,  or  by  an  indirect 
action  from  spasm,  it  is  acknowledged  that  the  ulcer 
acts  on  the  gastric  secretion,  that  it  causes  hyper- 
functionating  of  the  mucosa,  and  that  the  resulting 
hypersecretion  is  in  itself  baneful.  The  majority  of 
writers  agree  on  this  point ;  but  few  admit  the  primary 
action  of  the  ulcer,  and  the  majority  believe,  on  the 
contrary,  that  hyperchlorhydria  is  the  first  to  appear, 
and  that  it  is  the  primordial  cause,  or  at  least  the  con- 
dition sine  qua  non,  of  the  development  of  the  ulcer. 

Hence  the  very  clear  expose  given  by  Charles 
Robin  of  his  pathogenic  theory,  which  attributes  a 
capital  importance  to  gastric  hyperaesthesia  in  the 
development  of  ulcer.  According  to  this  observer, 
the  gastric  secretion  must  be  exaggerated  in  order 


GASTRIC  ULCER  131 

that  a  round  ulcer  shall  develop  ;  and  he  at  length 
comes  to  the  conclusion  that  the  lesion  is  merely  an 
episode  of  chronic  gastritis  present  for  a  long  time, 
and  that  the  process  is  only  produced  when  the 
affection  has  reached  the  stage  of  acid  gastritis.  This 
preponderating  influence  of  hyperchlorhydria  in  the 
formation  of  the  ulcer  is,  as  we  have  pointed  out, 
admitted  by  the  majority  of  recent  writers,  but  none 
acknowledge  that  this  cause  can  in  itself  alone 
produce  a  typical  round  ulcer.  In  order  that  this 
lesion  shall  become  declared  some  other  superadded 
cause  must  come  into  play. 

What  is  the  second  pathogenic  factor  ?  Should 
the  same  sole  factor  always  be  searched  for,  namely, 
interstitial  gastritis  or  a  localised  circulatory  dis- 
turbance ?  It  would  seem  more  logical  to  admit 
that  these  factors,  which  we  will  call  secondary, 
are  many  and  may  vary  from  one  case  to  another. 
We  shall  find  in  this  class  all  the  causes  which  have 
given  rise  to  the  multiple  hypotheses  proposed  up  to 
the  present  time. 

Katzenstein  has  nicely  expressed  the  very  principle 
of  this  idea  by  this  formula  :  H  +  C  =  ulcer.  H 
represents  hypersecretion,  and  C  a  circulatory  dis- 
turbance. 

But  Katzenstein's  scheme  appears  to  recognise  but 
a  single  secondary  cause,  namely,  circulatory  disturb- 
ances. To  give  a  broader  idea  of  the  pathogenesis, 
we  will  designate  by  C  any  secondary  cause  and  offer 
the  following  table  : — 
(1)  Principal  Cause. 

Gastric  hyperactivity. 

K    2 


132  SURGICAL  TREATMENT 

(2)  Secondary  Causes. 

Interstitial  gastritis. 

Localised  circulatory  disturbances. 

Blood  changes. 

Lesions  of  bacterial  origin. 

ToxaBmic  necrobiosis. 

Traumata. 

Therefore  hyperchlorhydria  should  be  envisaged 
as  a  propitious  soil  for  the  development  of  ulcer, 
without  which  the  secondary  causes  will  only  produce 
ulcers  with  a  rapid  evolution,  and  it  is  this  that 
explains  why  experimenters  have  never  been  able  to 
reproduce  ulcer  in  a  constant  or  regular  fashion  :  the 
necessary  soil  for  their  experiments  was  lacking. 
Besides  the  numerous  essays  of  various  experimenters, 
we  would  mention  three  clinical  cases  reported  by 
Robin  which  appear  to  us  characteristic  in  this 
respect.  Two  of  the  cases  were  typical  ulcers,  one 
in  a  furniture  remover,  who  had  a  ha3matemesis 
following  a  violent  blow  on  the  epigastrium,  the 
second  subject  vomiting  blood  following  the  kick  of 
a  horse  in  the  gastric  region  ;  both  were  hypersthenic 
dyspeptics  with  hyperchlorhydria. 

The  third  patient,  who  had  a  very  severe  hasma- 
temesis  caused  by  a  blow  from  a  shaft  of  a  cart,  and 
who  was  not  hyperchlorhydric,  recovered  in  a  few 
weeks  without  developing  ulcer. 

Buccal  infection,  especially  pyorrhoea  alveolaris, 
has  been  counted  among  the  pathogenic  factors  of 
gastric  ulcer."'?  That  this  may  be  so  cannot  be  denied 
in  some  few  instances,  but  we  fail  to  be  convinced 
that  it  is  a  frequent  cause,  as  some  would  have  it. 


GASTRIC  ULCER  183 

Were  it  so,  the  number  of  cases  of  ulcer  among  the 
poor,  as  well  as  those  negligent  of  the  ordinary 
hygienic  rules  of  life,  would  be  large,  and  it  has  not 
been  our  experience  to  find  that  the  state  of  the 
mouth  or  teeth  could  be  accounted  for  in  the  pro- 
duction of  the  majority  of  cases  coming  under  our 
observation. 

The  endocrinic  origin  of  peptic  ulcer  has  been 
suggested,  especially  by  G.  A.  Friedmann,  but  we 
cannot  accept  his  rather  too  theoretical  explanation. 
More  clinical  proof  is  desirable  before  hazarding  any 
conclusions  as  to  this  possible  pathogenesis  of  ulcer 
of  the  stomach. 

If  we  have  somewhat  lengthily  discoursed  on  the 
causes  of  gastric  ulcer,  it  is  only  because  it  is  necessary 
to  exactly  grasp  its  pathogenesis  in  order  to  institute 
a  really  rational  -treatment.  Otherwise  one  might 
be  content  with  blind  therapeutics,  which  have 
already  given  rise  to  many  disappointments,  rightly 
imputable  to  erroneous  ideas  entertained  about  this 
morbid  process. 

Briefly  put,  then,  a  gastric  ulcer  is  produced  by 
the  simultaneous  action  of  two  factors,  one  of  which 
— hyperchlorhydria — is  constant,  since  it  is  found  in 
all  cases,  and  the  other,  variable  in  nature,  may  be 
either  some  circulatory  disturbance,  a  trauma  or  the 
remains  of  a  general  or  local  infection. 

Thus,  knowing  the  two  pathogenic  factors  which 
exert  their  influence,  one  must  decide  upon  the  best 
means  by  which  to  overcome  them.  For  that  matter, 
from  what  we  have  said  it  is  evident  that  if  one  of  the 
factors  is  eliminated  a  sensible  effect  on  the  affection 


134  SURGICAL  TREATMENT 

in  general  may  be  obtained,  at  least  at  the  onset  of 
the  process.  We  know  one  of  the  causes,  since  it  is 
always  the  same  one,  that  without  it  round  ulcer  of 
the  stomach  will  not  develop  ;  therefore  it  can  be 
easily  dealt  with,  while  the  second  cause  is  unknown, 
at  least  in  the  majority  of  cases,  and,  as  it  is  unknown, 
no  really  effective  treatment  can  be  given. 

But  when  the  ulcer  is  already  formed  and  has 
assumed  a  chronic  evolution,  it  appears  to  us  that  it 
is  more  exact  to  attribute  less  importance  to  the 
secondary  factor,  as  it  is  only  important  in  regard  to 
the  formation  of  the  ulcer.  Consequently  the  treat- 
ment of  this  cause  will,  in  most  cases,  be  perfectly 
illusive,  and  no  effect  should  be  expected.  Therefore 
in  the  majority  of  cases,  when  the  ulcer  is  in  full 
evolution,  one  resource  remains,  namely,  to  deal  with 
the  hyperchlorhydria  and  place  the  stomach  at  rest 
by  avoiding  all  causes  of  irritation,  no  matter  how 
minute.  We  shall  show  in  the  next  chapters  how 
surgical  treatment  may  attain  this  end  in  cases 
where  medical  treatment  has  failed.  The  results 
obtained  are  such  that  one  may  conceive  in  what 
manner  the  various  procedures  exert  this  influence. 

Pathology 

It  is  not  our  intention  to  present  a  detailed  and 
exact  description  of  lesions  characterising  ulcer  of  the 
stomach  ;  it  only  seems  to  us  worth  while  to  refer  to 
some  points  that  appear  to  offer  a  particular  interest 
in  regard  to  surgical  treatment. 

When  speaking  of  gastric  stenoses,  we  remarked 
that  ulcer  developed  in  the  immediate  vicinity  of  the 


GASTRIC  ULCER  135 

pylorus  or  on  the  lesser  curvature  in  about  70  per 
cent,  of  the  cases.  This  localisation  is  interesting 
from  the  fact  that  even  if  cure  ensues  it  is  usually 
with  some  important  deformity  of  the  stomach. 

The  ulcer  is  generally  single,  but  cases  have  been 
recorded  in  which  several  lesions  were  undergoing 
simultaneous  evolution  at  different  parts  of  the  organ  ; 
and  although  such  instances  are  well  known,  it 
behoves  us  not  to  look  upon  them  as  rarities. 

The  dimensions  of  the  lesion  vary,  the  ulcer  usually 
being  from  1  to  3  centimetres  in  diameter ;  it  is  not 
uncommon  to  encounter  larger  ones,  some  attaining 
10  or  even  12  centimetres. 

One  of  the  distinctive  signs  of  round  ulcer,  which 
must  not  be  confounded  with  exulceratio  simplex,  is 
the  tendency  to  extend  not  only  in  surface,  but 
likewise  in  depth,  at  the  same  time  producing  a 
strong  tissue  reaction  in  front  of  it.  Thus  not  only 
the  mucosa,  but  also  other  strata,  of  the  gastric  wall 
become  actually  eaten  through.  Finally,  when  the 
process  reaches  the  deeper  layers  of  the  wall,  the 
ulcer  reacts  on  the  peritoneum,  producing  adhesions, 
which  it  dips  into  later  on.  Thus,  by  con- 
tinuously burrowing,  it  may  penetrate  the  paren- 
chyma of  adjacent  viscera,  especially  the  liver  and 
pancreas,  and  a  case  is  even  recorded  by  Ziegler  in 
which  the  ulcer,  having  traversed  the  diaphragm  and 
pericardium,  ended  by  perforating  the  heart. 

When  the  ulcer  penetrates  the  parenchyma  of  an 
organ,  it  provokes  a  strong  tissue  reaction ;  and  hence 
it  results  that  the  lesion  is  no  longer  in  direct  contact 
with  the  glandular  parenchyma,  but,  on  the  contrary, 


186  SUEGICAL  TREATMENT 

the  latter  is  usually  separated  from  the  ulcer  by  a 
more  or  less  thick  fibrous  shell,  composed  of  inflam- 
matory tissue  with  a  poor  vascular  supply.  The 
latter  is  only  composed  of  pre-existing  vessels 
embedded  in  callous  mass,  having  lost  all  elasticity, 
so  that  they  can  aptly  be  compared  to  tunnels 
hollowed  out  in  rock.  An  erosion,  even  minute,  of 
their  walls  will  therefore  remain  gaping  ;  it  cannot 
retract,  and  this  explains  the  haemorrhage,  some- 
times formidable,  that  ensues,  by  no  means  what 
might  be  expected  from  the  insignificant  lesion 
giving  rise  to  it. 

The  reactional  tissue,  at  least  at  a  relatively  recent 
period  of  its  development,  is  also  distinguished  by 
the  peculiarity  of  being  excessively  friable,  in  spite  of 
its  deceptive  hardness.  Any  one  who  has  attempted 
to  suture  a  perforated  chronic  ulcer  will  have  been 
able  to  convince  himself  with  what  great  ease  the 
sutures  cut  through.  This  also  applies  when  an 
attempt  is  made  to  separate  the  ulcer  from  an 
adjacent  organ  that  it  has  invaded.  Tears  occur, 
in  spite  of  every  precaution,  in  these  indurated 
tissues,  which  appear  to  be  so  firm. 

When  the  inflammatory  process  subsides  and  the 
phenomena  of  cicatrisation  commence,  this  area  of 
sclerous  tissue  may  disappear  completely.  The 
mucosa  proliferates  at  the  edges  of  the  ulcer  and 
finally  covers  the  lesion  completely,  while  in  this 
newly  formed  mucosa  more  or  less  normal  glands  are 
found ;  the  submucosa  likewise  regenerates,  so  that 
it  is  often  impossible  to  discover  any  trace  of  the 
former  ulcer  on  the  internal  aspect  of  the  stomach, 


GASTRIC  ULCER  187 

but  this  is  made  evident  on  the  outer  aspect  of  the 
organ  by  a  cicatrix  of  the  peritoneum.  In  fact, 
although  the  mucosa  regenerates  to  the  extent  of 
assuming  a  normal  aspect,  the  muscularis  cannot 
reform,  and  is  replaced  by  cicatricial  connective  tissue, 
which  forms  a  localised  induration  with  radiating 
folds  resulting  from  contraction.  The  lesions  of  the 
peritoneum  likewise  always  remain  visible,  either 
on  account  of  adhesions  with  the  adjacent  organs 
which  cannot  be  absorbed,  or  by  radiating  whitish 
cicatrices. 

When  the  ulcer  is  seated  on  the  anterior  wall  of 
the  stomach,  which  is  not  the  least  frequent  of 
all  its  sites,  it  may  reach  the  peritoneum  of  the 
organ  without  the  periulcerous  reactional  zone  giving 
rise  to  adhesions.  The  intestines  and  omentum  are 
too  mobile  for  the  latter  to  acquire  thickness  and 
resistance.  Therefore  the  ulcer  extends  in  depth, 
and  is  no  longer  separated  from  the  peritoneal  cavity 
than  by  the  invariably  thin  lamina  of  the  eminently 
friable  sclerous  tissue. 

If  the  lesion  still  progresses,  a  slight  increase  of  the 
intragastric  pressure  will  cause  this  thin  lamina  to 
give  way  en  masse,  so  that  a  complete  perforation 
may  take  place,  involving  the  entire  surface  of  the 
ulcer.  A  loss  of  tissue,  as  if  punched  out,  will  then 
be  found,  its  diameter  often  measuring  several  milli- 
metres. The  clean-cut  edges  are  sclerosed,  and  do  not 
allow  any  retraction  of  the  tissues  to  take  place. 
This  is  what  imparts  the  exceptional  gravity  to 
perforation  of  gastric  ulcer  in  general,  and  especially 
to  ulcer  of  the  anterior  gastric  wall.  Peritoneal 


138  SUEGICAL  TEEATMENT 

inundation  from  the  gastric  contents  occurs  suddenly 
and  en  masse.  There  is  little  chance  of  localisation 
of  the  process  in  these  circumstances,  so  that  an 
encysted  abscess  may  develop,  as  occasionally  occurs 
after  perforation  of  an  ulcer  on  the  posterior  gastric 
wall.  Consequently  the  peritonitis  will  be  general 
from  the  onset  in  most  cases,  and  from  this  fact  offers 
a  high  degree  of  gravity,  noted  by  all  who  have 
studied  the  peritonitides  and  their  causes. 

Such  are  the  few  points  to  which  we  desire  to  call 
attention,  a  complete  study  of  the  lesions  produced 
by  ulcer  of  the  stomach  offering  no  real  interest  from 
our  point  of  view,  and  therefore  being  beyond  the 
intended  limits  of  this  book.  It  is  important,  however, 
to  be  aware  that  ulcers  are  met  with,  in  the  vast 
majority  of  cases,  at  points  where  a  cure  may  even 
result  in  serious  disturbances  from  stenosis,  that  they 
are  surrounded  by  zones  of  inflammatory  indurated 
fibrous  tissue,  but  having  little  resistance,  conditions 
which  seriously  complicate  interferences  directly 
dealing  with  the  ulcers.  Finally,  in  the  very  interior 
of  the  fibrous  shell  the  eroded  vessels  cannot  collapse 
on  themselves,  and  are  the  source  of  often  very  intense 
haemorrhage. 

We  also  wish  to  show  that  perforation  of  the  ulcer 
is  usually  a  sudden  perforation  with  massive  irruption 
of  the  gastric  contents  when  adhesions  have  not 
previously  formed  and  act  as  a  protecting  barrier 
to  the  peritoneal  cavity.  These  adhesions  delimiting 
the  peritonitis  are  generally  met  with  in  ulcer  of  the 
posterior  gastric  wall,  while  they  are  hardly  to  be 
anticipated  in  ulcer  of  the  anterior  wall,  which  can 


GASTRIC  ULCER  189 

readily  be  conceived,  given  the  anatomical  relation- 
ship of  the  parts. 

Evolution 

The  majority  of  writers  are  unanimous  in  acknow- 
ledging that  it  is  practically  impossible  to  offer  a 
description  of  typical  evolution  of  ulcer  of  the 
stomach.  Varying  in  its  symptoms,  gravity  and 
progress,  the  lesion  is  an  eminently  deceitful  process, 
and  it  is  impossible  to  say  when  it  begins  or  how  and 
when  it  will  end.  Latent  ulcers,  only  giving  rise  to 
such  indefinite  symptoms  during  life  that  no  diagnosis 
is  made,  and  chronic  ulcers,  which  for  years  compel 
certain  patients  to  give  themselves  up  to  almost 
continual  treatment,  represent  the  two  extremes  of 
the  process  between  which  are  acute  ulcers,  relapsing 
ulcers,  and  then  a  slowly  progressive  gradation  of 
other  lesions,  making  classification  impossible.  There- 
fore we  are  obliged  to  take  certain  typical  evolutions 
which  will  serve  as  a  basis  for  a  solely  theoretical 
classification.  Debove  and  Achard  are  about  the 
only  authors  who  have  written  a  chapter  on  the 
evolution  of  ulcers  of  the  stomach  ;  they  distinguish 
three  schematic  types  of  this  evolution  : — 

(1)  Ulcer  with  a  "  normal "  progress,  which, 
according  to  these  observers,  undergoes  its  evolution 
in  from  six  to  eighteen  months,  ending  in  cure, 
although  these  figures  are  by  no  means  absolute, 
because,  as  we  have  said,  it  is  just  as  impossible  to 
precisely  specify  the  onset  of  the  process  as  it  is  to 
affirm  that  a  definite  cure  has  taken  place. 

This  long  duration  of  ulcer,  admitted   by  these 


140  SURGICAL  TREATMENT 

writers,  does  not  appear  to  correspond  with  the 
generally  accepted  facts.  The  majority  of  internists 
consider  that  the  usual  duration  of  round  ulcer  is  a 
month  to  six  weeks  ;  at  least,  it  is  during  an  equivalent 
time  that  treatment  should  be  regularly  followed,  as 
von  Leube,  for  example,  has  proposed. 

This  is  the  duration  that  the  majority  of  physicians 
have,  we  believe,  accepted.  Lenhartz,  Rosenfeld, 
von  Leube,  von  Muller,  A.  Schmidt  and  von  Taboro 
consider  that  a  cure  should  be  obtained  at  the  end  of 
four  to  five  weeks'  treatment.  Among  the  Germans 
Fleiner  is  the  only  one  who  states  that  he  meets 
with  long-standing  cases,  and  asks  if  these  long-stand- 
ing cases,  recurrences  and  stenoses  would  occur  if  the 
number  of  cures  reported  corresponded  to  the  truth. 

Several  writers,  as  we  have  said,  have  noted  how 
numerous  such  recurrences,  relapses  and  incomplete 
cures  are  when  careful  search  is  made  for  the  ultimate 
fate  of  patients  regarded  as  cured  when  discharged 
from  hospital  and  classified  as  such  in  the  dazzling 
and  alluring  statistics  of  certain  German  writers 
more  especially,  who  pretend  that  they  have  a 
mortality  of  only  2-5  per  cent.,  as  von  Leube  and 
Lenhartz  would  have  us  believe. 

A  distinction  must  be  made  between  the  dis- 
appearance of  the  symptoms  and  an  anatomical  cure, 
that  is  to  say,  perfect  cicatrisation. 

Simple  gastric  ulcer  has  unquestionably  a  much 
slower  evolution,  this  being  one  of  its  characteristics ; 
but  it  is  difficult  to  offer  figures  indicating  an 
average,  or  even  an  approximate,  time  in  which  this 
shall  take  place.  It  is  generally  acknowledged  that 


GASTRIC  ULCER  141 

in  young  people  the  ulcer  tends  to  cicatrise  with 
greater  rapidity  on  the  condition  that  they  will 
submit  to  regular  and  strict  treatment,  but,  on  the 
other  hand,  it  more  frequently  exposes  the  subject 
to  perforation  or  haemorrhage  when  the  age  of  thirty - 
five  is  passed.  After  thirty-five  the  lesion  is  more 
torpid,  but  infinitely  more  tenacious. 

Ulcer  with  Chronic  Evolution. — According  to 
Debove  and  Achard,  as  well  as  other  recent 
writers  on  the  subject,  this  type  of  ulcer  is  very  much 
more  frequent  than  was  generally  supposed.  We 
have  already  referred  to  the  writings  of  Warren 
and  of  Schulz,  and  we  will  also  give  the  results  of 
researches  made  by  Gunsbourg  and  Joslin.  These 
observers  found  that  out  of  a  total  of  114  cases  that 
were  declared  cured  at  the  time  they  were  discharged 
from  hospital  twenty-three  died  within  five  years  of 
their  discharge  from  complications  due  to  the  ulcer, 
and  forty-one  had  frequently  recurring  relapses.  It 
will,  therefore,  be  seen  that  all  these  writers  are  in 
accord  on  this  point,  that  the  ultimate  outcome 
of  ulcer  cases  is  often  unknown  and  that  chronicity 
of  the  affection  is  the  rule  in  about  50  per  cent,  of 
the  cases. 

It  is  not  uncommon  to  meet  with  chronic  ulcers 
dating  back  anywhere  from  five  to  fifteen  years  or  even 
very  much  longer,  during  which  time  the  very  exist- 
ence of  the  patient  has  been  one  of  torture.  Usually 
a  chronic  ulcer  proceeds  in  acute  outbursts,  with 
periods  of  remission  variable  in  length,  a  fact'  that 
has  been  the  means  of  leading  one  to  suppose  that 
relapses  took  place  in  many  cases  when  in  reality 


142  SURGICAL  TREATMENT 

they   were   successive    aggravations    of    a    chronic 
process. 

These  periods  of  aggravation  in  which  all  the 
symptoms  of  acute  ulcer  reappear — or  it  may  be  only 
one  symptom,  usually  the  same  one — often  occur 
with  a  certain  periodicity,  and  are  not  foreign  to 
some  remote  causes,  such  as  moral  influences,  etc. 
When  the  predominating  symptom  takes  the  form 
of  gastralgia,  the  first  diagnosis  will  probably  be  that 
of  neuropathy,  which  is  far  too  greatly  a  la  mode  at 
the  present  time. 

As  to  the  causes  of  chronicity  of  the  ulcer,  we 
referred  to  them  in  part  when  speaking  of  the 
pathogenesis  of  this  affection,  but  besides  the  hyper- 
chlorhydria  to  which  such  great  importance  is 
attached,  the  findings  of  Smithies  notwithstanding, 
the  difficulty  for  the  ulcer  to  heal  when  it  has  involved 
the  parenchyma  of  the  liver  or  pancreas  must  not  be 
overlooked.  Although  the  gastric  mucosa,  or  even 
the  muscularis,  may  regenerate,  the  sclerosed  fundus 
of  the  ulcer,  formed  by  a  non-retractile  organ,  cannot 
fill  up.  Cicatrisation  can  take  place  to  a  certain 
extent,  but  a  residuum  of  the  ulcerated  surface  will 
invariably  subsist,  the  starting-point  of  perpetual 
irritation,  exercising  its  influence  either  on  the  pylorus 
— hence  spasm — or  on  the  glandular  system  of  the 
stomach.  Moreover,  this  deep  lesion,  a  cavity,  so  to 
speak,  is  always  accessible  to  infection,  and  the  sudden 
exacerbations  of  the  ulcer  may  be  compared  to 
acute  inflammatory  attacks  occurring  in  granulating 
wounds  undergoing  cicatrisation,  but  which,  for  some 
reason,  have  again  become  infected. 


GASTRIC  ULCER  143 

Hence  it  ensues  that  medical  treatment  has  little 
effect  on  the  ulcer  when  the  process  has  entered  upon 
the  chronic  stage.  Medical  treatment  may  cause  a 
sensible  amelioration,  a  diminution  of  the  alarming 
symptoms,  as  it  does  in  cases  of  ulcer  at  the  onset, 
but  it  would  be  very  difficult  for  it  to  bring  about  a 
permanent  cure  of  chronic  ulcer  in  the  vast  majority 
of  cases.  The  recovery  can  only  be  apparent,  and 
relapse  or  recurrence  will  not  be  long  in  becoming 
manifest. 

However,  occasionally  medical  treatment  will 
attain  satisfactory  results.  In  order  that  this  shall 
occur,  it  must  be  continued  for  a  sufficient  length  of 
time,  and  requires  on  the  patient's  part  a  great  degree 
of  goodwill.  The  chemical  and  motor  disturbances 
progressively  subside,  and  cicatrisation  of  the  ulcer 
ensues  ;  the  mucosa  finally  replaces  the  loss  of  sub- 
stance, even  when  extensive.  The  inflammatory 
reaction  of  the  adjacent  tissues  subsides,  the  infiltra- 
tion becomes  absorbed,  and  even  the  adhesions  on  the 
peritoneal  surface  of  the  stomach  may  become  soft  or 
even  disappear.  Nevertheless  when  the  adhesions  are 
old,  fibrous  and  distinctly  organised,  such  an  outcome 
is  hardly  to  be  anticipated,  even  when  the  ulcer  has 
undergone  complete  cicatrisation. 

Moreover,  when  the  site  of  the  ulcer  is  at  the 
pylorus,  when,  by  successive  acute  exacerbations  or 
the  constant  inflammation  kept  up  by  the  lesi<5n, 
a  sclerous  process  develops,  as  well  as  tumefaction 
of  the  tissues  at  this  already  narrow  part,  a  stenosis 
will  inevitably  result  and  persist  even  after  the  cure 
of  the  ulcer.  The  consequences  of  this  stenosis,  often 


144  SUBGICAL  TEEATMENT 

very  narrow,  will  be  decreased  by  the  cure  of  the 
ulcer  from  the  fact  that  the  spasm  which  accompanies 
the  majority  of  ulcer  cases  subsides,  nevertheless  a 
more  or  less  pronounced  difficulty  in  the  pyloric 
transit  will  be  evident. 

These  adhesions  and  stenoses,  generally  pyloric, 
occasionally  mediogastric — biloculation  of  the  sto- 
mach— are  considered  as  complications  of  ulcer  by 
the  majority  of  writers  ;  in  fact,  they  are  what  we 
should  call  the  normal  ultimate  result  of  chronic  ulcer 
when  the  lesion  has  undergone  an  evolution  towards 
cure.  Otherwise  put,  they  are  the  sequelae  of  ulcer. 

Medical  treatment  is  without  avail  in  these 
sequelae,  which  are  the  origin  of  serious  and  often 
ill-defined  disturbances.  On  the  other  hand,  surgical 
treatment  reigns  supreme. 

Acute  Ulcer. — Although  much  less  frequent,  an 
ulcer  may  assume  a  particularly  rapid  evolution,  or 
at  least  such  would  appear  to  be  the  case.  The  first 
manifestation  of  the  affection  often  is  a  complication 
arising  suddenly  in  subjects  in  apparently  excellent 
health,  death  ensuing  in  a  few  hours  or  days.  In 
these  cases  it  is  a  question  whether  the  ulcer,  which 
had  hardly  developed,  could  have  undergone  such  a 
rapid  evolution  as  to  give  rise  to  a  fatal  haemorrhage 
or  perforation.  Usually  this  is  not  the  case,  the  ulcer 
having  followed  a  regularly  "  normal,"  but  silent, 
progress.  Strictly  speaking,  it  is  not  the  evolution 
which  is  acute,  but  rather  the  appearance  of  the 
symptoms.  This  distinction  is,  for  that  matter,  more 
theoretical  than  practical,  since  a  torpid  ulcer  may 
evolve  without  giving  the  slightest  symptom  and 


TYPICAL   GASTRIC  ULCER  145 

remain  latent  even  for  those  who  search  for  it  with 
the  closest  attention. 

The  Clinical  Forms  of  Ulcer 

It  is  quite  impossible  to  offer  a  rational  classifica- 
tion of  the  various  clinical  forms  of  ulcer  of  the 
stomach.  More  than  for  any  other  lesion,  this  classi- 
fication could  only  be  eminently  artificial,  because  the 
affection  under  consideration  is  too  variable  in  its 
evolution,  pathology  and  symptomatology.  Moreover, 
the  differences  are  not  sufficiently  accentuated  among 
the  cases,  so  that  the  same  ulcer  may  pass  through 
the  divers  phases  which  would  successively  include 
it  under  different  typical  forms  of  the  process. 

The  majority  of  writers  merely  recognise  two 
distinct  groups  of  ulcer,  namely,  acute  and  chronic. 
This  classification  is  the  only  logical  one,  but  we  look 
upon  it  as  somewhat  insufficient,  while  it  is  evident 
that  a  clinical  distinction  of  these  forms  is  in  most 
cases  impossible  to  make. 

Many  writers  have,  nevertheless,  used  this  classi- 
fication for  establishing  their  indications  for  surgical 
interference.  The  acute  ulcer  should  be  treated  medi- 
cally, the  chronic  ulcer  belonging  to  the  domain  of 
surgery.  There  still  remain  the  complications  to 
which  the  lesion  gives  rise,  which  for  these  writers 
are  likewise  surgical. 

If  a  classification  is  desired  to  serve  as  a  foundation 
for  the  study  of  therapeutical  indications,  it  appears 
to  us  more  logical  to  distinguish  the  forms  of  ulcer 
according  to  the  symptoms  predominating  in  each 
case. 


S.T. 


146  SUEGICAL  TEEATMENT 

As  Debove  and  Achard  remark,  such  or  such  a  sign 
of  ulcer  may  become  predominant  and  create  a  rather 
special  aspect  of  the  affection.  They  add :  "  It  is  not, 
strictly  speaking,  forms  of  ulcer,  because,  viewed  in 
this  way,  the  same  patient  might  successively  present 
different  forms,  according  to  the  predominating 
symptom,  such  as  vomiting,  hemorrhage  or  a 
cachectic  state." 

It  is  certain  that  from  the  theoretical  view-point 
a  classification  based  on  the  various  symptomatic 
modalities  cannot  be  exact.  In  practice  they  will, 
on  the  contrary,  allow  a  clearer  discussion  in  regard 
to  therapeutical  indications ;  and,  as  this  is  what 
interests  us  at  present,  we  shall  distinguish  the 
following  forms  of  gastric  ulcer  : — 

Typical  ulcer. 

Hasmorrhagic  ulcer. 

Gastralgic  ulcer. 

Ulcer  with  a  predominance  of  vomiting. 

Ulcer  with  cachexia. 

Latent  ulcer. 

Typical  Ulcer. — Strictly  speaking,  there  is  no 
typical  form,  but  by  this  denomination  we  mean  the 
vulgar  type  most  frequently  met  with.  It  corre- 
sponds to  what  many  writers  call  round  ulcer  or 
simple  peptic  ulcer.  There  is  no  predominating 
symptom ;  the  process  undergoes  its  evolution, 
accompanied  by  its  train  of  distinct  and  well-marked 
symptoms — pain,  vomiting,  mild  haemorrhage  and 
hyperchlorhydria — for  a  variable  length  of  time,  to 
which  no  limit  can  be  made.  The  acute  ulcer  is 
recovered  from  in  a  few  months ;  the  chronic  ulcer 


TYPICAL  GASTRIC  ULCER  147 

may  last  for  years  with  periods  of  remission,  but  never 
change  in  character.  It  is  by  its  duration  that 
the  chronic  lesion  ends  by  profoundly  acting  on  the 
general  health. 

There  is  no  prominent  feature  in  the  history  of 
these  cases,  and  we  have  nothing  to  add  in  this 
respect  that  is  not  already  general  knowledge.  It  is 
this  form  of  ulcer  that  is  found  described  in  all  the 
text-books ;  hence  there  is  no  need  for  its  dis- 
cussion here. 

Haemorrhagic  Ulcer. — Haemorrhage  is  one  of  the 
cardinal  symptoms  of  ulcer,  and,  at  the  same  time, 
is  one  of  the  most  frequent  if  carefully  searched  for. 
Moreover,  haBmorrhage  is  often  the  first  symptom 
of  ulcer.  Likewise  it  is  often  the  one  that  strikes 
the  patient  and  leads  him  to  take  care  of  his  health, 
although,  perhaps,  he  has  been  suffering  for  some 
time  with  vague  gastric  symptoms  to  which  he  gave 
little  attention. 

In  this  way  the  haemorrhage — a  frequent  symptom 
— imparts  a  special  character  to  the  ulcer  in  a  rather 
large  number  of  instances,  while,  at  the  same  time,  it 
also  has  its  importance  on  account  of  the  peculiar 
indications  that  it  may  give  in  regard  to  proper 
treatment. 

There  are  three  recognised  typical  forms  of 
haemorrhage : — 

The  first  is  fulminating  haemorrhage,  which  results 
in  marked  anaemia  of  the  patient  in  a  few  hours  ;  it 
is  due  to  an  erosion  of  some  large  artery,  such  as  the 
splenic,  more  frequently  the  coronary,  and  more 
rarely  the  pancreatico-duodenal  artery.  This  hyper- 

L  2 


148  SURGICAL  TREATMENT 

acute  haemorrhage  is  especially  common  in  acute  ulcer, 
and  is  met  with  principally  in  subjects  still  young. 
It  arises  in  the  midst  of  flourishing  health,  following 
a  copious  meal,  strain  or  exertion.  Death  ensues  so 
quickly  that  medical  treatment  is  of  no  avail. 

The  second  form  is  the  serious  repeated  haemor- 
rhage with  a  sudden  onset,  but  the  loss  of  blood  is 
not  generally  so  great  as  in  the  preceding  form  and 
usually  can  be  controlled  in  a  few  days  by  energetic 
treatment.  The  patient  is  greatly  weakened  from 
the  attack,  and  having  been  thoroughly  frightened 
by  the  alarming  symptoms,  will  usually  follow  strict 
treatment  and  medical  advice  until  the  day  comes 
when  he  believes  all  danger  has  been  passed.  The 
consequence  of  neglect  of  medical  care  will  soon  be 
felt  by  the  advent  of  another  haemorrhage  of  the  same 
character  as  the  first. 

In  the  majority  of  cases  these  serious  repeated 
haemorrhages  occur  in  ulcers  having  a  chronic 
tendency,  and  become  more  and  more  free  until  death 
ensues. 

The  third  form  is  when  the  haemorrhage  assumes  a 
more  deceitful  aspect.  At  first  less  disquieting  than 
the  two  preceding  forms,  it  recurs  more  frequently. 
From  time  to  time  there  is  a  little  vomiting  of  black 
blood  with  some  pain,  or  simply  a  feeling  of  distress 
and  weight  in  the  epigastric  region.  These  are  the 
only  symptoms  of  loss  of  blood,  which  at  length  reacts 
on  the  general  health.  It  is  only  after  a  time,  and  by 
their  repetition,  that  these  losses  of  blood  produce 
anaemia  or  even  cachexia. 

These  small  repeated  haemorrhages  lead  to  the 


TYPICAL  GASTRIC  ULCER  149 

more  common  latent  haemorrhages,  which  are  only 
detected  by  methodical  examination  of  the  faeces. 
They  occur  in  a  large  percentage  of  cases,  and  their 
only  importance  is  that  they  often  affirm  the  pre- 
sence of  a  torpid  ulcer.  For  this  reason  examina- 
tion of  the  faeces  should  never  be  neglected  whenever 
there  is  the  slightest  suspicion  of  gastric  ulcer, 
fluoroscopy  notwithstanding.  The  examination 
should  be  repeated  on  several  occasions,  because,  the 
bleeding  not  being  continual,  the  guaiacum  reaction 
will  be  present  for  several  days,  and  then,  during  a 
variable  length  of  time,  examination  will  give 
negative  results. 

On  the  contrary,  when  the  ulcer  undergoes  malig- 
nant transformation,  a  not  infrequent  complication, 
the  loss  of  blood  becomes  more  and  more  frequent,  so 
that  the  guaiacum  reaction  in  the  faeces  becomes  con- 
stantly positive.  This  is  even  one  of  the  reliable 
differential  diagnostic  signs  between  ulcer  and  cancer, 
because  it  occurs  earlier  in  neoplastic  transformation 
than  do  changes  of  the  gastric  chemism. 

Gastralgic  Ulcer. — The  pain  in  ulcer  of  the  stomach 
is  of  different  kinds.  In  some  the  early  appearing 
pain  is  unaccounted  for,  and  its  origin  is  still  a  moot 
subject ;  in  other  instances  the  late  occurring  pain — 
and  this  is  more  common — can  be  better  explained 
and  lends  itself  less  to  discussion. 

Some  writers  consider  that  early  pain  is  due  to 
irritation  of  the  ulcer  itself,  similar  to  what  takes 
place  in  any  open  wound.  But  these  writers  seem 
to  forget  that  the  gastric  wall  is  perfectly  devoid  of 
sensibility,  as  we  know  from  gastric  operations  done 


150  SURGICAL  TREATMENT 

with  local  anaesthesia.  Others  assume  that  the 
special  acidity  of  HC1  is  the  origin  of  the  pain. 
Several  observers,  in  fact,  admit  that,  although  the 
stomach  is  insensible  to  touch  or  mechanical  irrita- 
tion, this  does  not  apply  to  chemical  irritation.  But 
we  would  add  that,  so  far  as  we  know,  no  special 
study  has  been  undertaken  on  this  subject. 

Finally,  the  majority  of  writers  recognise  that  the 
pain  is  due  less  to  the  ulcer  than  to  distant  dragging. 
We  have  already  indicated  the  origin  of  this  pain 
when  speaking  of  perigastric  adhesions,  so  that  little 
more  need  be  said. 

However,  at  present  it  is  becoming  more  generally 
recognised  that  the  pain,  especially  the  so-called 
early  pain — that  is  to  say,  coming  on  immediately 
or  soon  after  eating — is  a  sure  sign,  others  even  say 
pathognomonic,  of  gastric  neuropathy.  Although 
there  can  be  no  question  but  that  many  gastralgias 
are  solely  the  result  of  a  neuropathic  state  and  a 
hypersensibility  of  the  solar  plexus,  it  is  an  exaggera- 
tion and  most  dangerous  to  regard  this  sign  as  certain. 
In  all  such  cases  we  cannot  too  strongly  insist  that 
careful  and  persistent  search  for  other  symptoms  of 
gastric  ulcer  should  be  carried  out,  such  as  X-ray 
examination,  hyperchlorhydria  and  occult  blood  in 
the  faeces. 

As  to  late  pain,  it  is  usually  due  to  a  pyloric  or 
prepyloric  lesion,  and  in  the  vast  majority  of  cases 
is  accompanied  by  stenosis  with  phenomena  of  stasis, 
which  should  clinch  the  diagnosis. 

There  is  pain  provoked  by  pressure  just  like  the 
early  pain,  very  variable,  according  to  the  case. 


TYPICAL   GASTEIC   ULCER  151 

Many  writers  still  cling  to  the  opinion  that  it  is  a  sign 
of  neuropathy.  They  base  this  assertion  on  the  fact 
that  the  so-called  pyloric  point  in  reality  corresponds 
to  a  semilunar  ganglion  and  solar  plexus.  Pain  on 
pressure  nevertheless  indicates  a  lesion  in  the  pyloric 
or  prepyloric  region  in  the  vast  majority  of  cases,  and, 
like  the  early  pain,  one  must  not  be  too  exclusive  in 
the  theoretical  interpretation  of  this  symptom. 

Ulcer  with  Predominance  of  Vomiting. — This  form 
of  ulcer  is  extremely  rare,  but  some  cases  have  been 
reported  in  which  the  sole  apparent  symptom  con- 
sisted of  frequently  repeated  vomiting  of  food, 
having  the  appearance  of  nervous  vomiting.  How- 
ever, an  attentive  examination  will  detect  other  signs 
of  ulcer,  so  that  this  form  offers  no  particular  interest. 

Ulcer  with  Cachexia. — Often  impossible  to  differ- 
entiate from  malignant  disease,  ulcer  with  cachexia 
usually  assumes  a  chronic  progress,  slow  and 
insidious.  It  is  often  accompanied  by  small  losses  of 
blood,  which  from  repetition  produce  anaemia. 
These  ulcers,  which  react  upon  the  health  in  such  a 
peculiar  way,  are  generally  located  at  the  pylorus, 
where  they  produce  stenosis  and  gastric  stasis.  To 
the  anaemia,  resulting  from  repeated  haemorrhage, 
the  influence  of  a  true  intoxication  from  gastric 
fermentation,  the  result  of  stasis,  becomes  added. 
As  Debove  and  Achard  remark,  this  form  simulates 
cancer,  and  is  all  the  more  liable  to  cause  an  error  in 
the  diagnosis  because  ulcer  frequently  undergoes 
malignant  neoplastic  transformation.  It  is  often 
impossible  to  decide  at  what  time  this  transformation 
takes  place. 


152  SUKGICAL  TREATMENT 

Latent  Ulcer. — We  have  several  times  spoken  of 
this  deceitful  lesion,  which  may  evolve  and  heal 
without  giving  rise  to  symptoms,  just  as  it  may  make 
itself  known  by  a  sudden  fatal  haemorrhage  or 
perforation.  Like  all  the  latent  forms  of  ulcer  in 
general,  latent  gastric  ulcer  will  diminish  in  frequency 
when  it  is  generally  recognised  and  searched  for. 
With  our  modern  diagnostic  means,  the  lesion  should 
be  detected  in  most  cases. 


CHAPTER   VII 

THE     OPEEATIVE     INDICATIONS     IN     TYPICAL     GASTRIC 

ULCER 

BOTH  medical  and  surgical  writers  acquiesce  in  at 
least  one  point,  namely,  that  surgical  treatment  is 
not  indicated  in  ordinary  typical  gastric  ulcer.  The 
great  majority  of  these  ulcers  heal  completely  and 
permanently  by  well-conducted  and  sufficiently  pro- 
longed medical  treatment.  This  form  of  lesion, 
therefore,  hardly  interests  the  surgeon  in  general ; 
nevertheless  it  offers  certain  contingencies  which 
render  operation  necessary. 

This  subject  is  one  of  the  most  moot  points  of 
gastric  surgery  ;  it  has  been  studied  and  discussed 
ever  since  1897,  when  Mikulicz  and  von  Leube 
brought  it  before  the  German  Surgical  Society  and 
formulated  the  indications  for  operative  interference 
which  are  still  followed  by  most  surgeons.  Von 
Leube  believes  that  simple  ulcer,  that  is  to  say,  an 
ulcer  in  activity,  but  without  complications,  belongs 
essentially  to  the  domain  of  medicine.  He  maintains 
that  medical  treatment  regularly  followed  for  a  month 
to  six  weeks  will  result  in  a  cure  in  the  vast  majority  of 
cases.  If  at  the  end  of  this  time  a  cure  is  not  wrought, 
there  may  be  a  question  of  surgical  interference. 

This  opinion  fairly  well  sums  up  the  ideas  of  the 
majority  of  observers,  among  whom  are  to  be  men- 
tioned Mayo-Robson,  Moynihan,  Czerny,  Kroenlein, 


154  SUEGICAL  TREATMENT 

Hartmann,  Soupault,  Monprofit,  to  mention  the  most 
important.  Other  physicians  for  the  most  part  main- 
tain that  medical  treatment  should  be  persevered  in 
longer.  This  divergence  of  opinion  is  due  to  the  fact 
that  these  observers  are  not  of  the  same  mind  in 
regard  to  the  duration  of  ordinary  simple  ulcer. 
Some  believe  that  an  ulcer  which  resists  a  carefully 
carried-out  treatment  for  two  months  is  to  be  regarded 
as  a  chronic  ulcer.  Others  suppose  that  it  requires  a 
much  longer  time  for  an  ulcer  to  lose  its  character 
of  ordinary  ulcus  simplex. 

Now  it  is  recognised  that  in  acute  ulcer  medical 
treatment  suffices  in  the  great  majority  of  cases,  while 
this  treatment  has  little  influence  when  the  lesion  has 
passed  to  the  chronic  form.  Therefore,  in  these 
circumstances,  surgical  treatment  should  be  resorted 
to.  Those  who  believe  in  prolonging  medical  treat- 
ment dread  the  dangers  of  an  operation  which  they 
consider  superfluous.  On  the  contrary,  those  who 
advise  early  surgical  interference  fear  the  dangers 
inherent  to  chronic  ulcer — perforation,  haemorrhage 
and  its  consequences — as  well  as  declining  health  and 
a  derangement  of  the  gastric  functions,  which  are  so 
difficult  to  put  in  order  after  operation. 

As  we  have  already  said,  when  speaking  of  pyloric 
stenosis,  we  believe  that  no  fixed  rule  can  be  made  in 
respect  to  the  duration  of  medical  treatment.  The 
ulcer  is  so  variable  in  its  evolution  that  each  case 
must  be  judged  by  itself,  and  we  must  not  attempt  to 
establish  a  theory  which,  although  true  in  some  cases, 
will  certainly  be  erroneous  in  others. 

The  most  that  can  be  said  is  that  all  observers  are 


TYPICAL  GASTRIC  ULCER  155 

unanimous  in  recognising  that  medical  treatment  of 
one  month's  duration  is  necessary  before  deciding  on 
operation.  This  lapse  of  time  is,  so  to  speak,  the 
minimum,  and  therefore  can  be  regarded  as  a  general 
rule  as  long  as  the  ulcer  remains  an  ordinary  typical 
lesion,  the  only  form  we  are  considering  in  this  chapter. 

To  this  minimum  of  one  month  is  to  be  added  a 
more  or  less  long  lapse  of  time  during  which  medical 
treatment  may  be  followed  with  profit,  and  this  lapse 
of  time  will  be  fixed  by  the  various  circumstances 
which  govern  each  case  in  particular.  These  circum- 
stances, which  may  vary  the  duration  of  medical 
treatment,  are  of  very  different  orders. 

Ulcer  of  the  stomach  is  an  essentially  perfidious  and 
fallacious  morbid  process,  which  from  this  fact  should 
be  closely  followed,  as  an  alarm  is  always  possible ;  but 
if  it  is  evident  that  the  process  has  a  tendency,  although 
slow,  to  recovery,  treatment  may  be  prolonged  much 
longer  than  is  generally  admitted.  On  the  contrary, 
if  the  ulcer  remains  stationary,  regardless  of  treat- 
ment, and  especially  when  this  is  regularly  followed 
— a  frequent  difficulty  in  practice — it  is  to  be  feared 
that  the  affection  has  assumed  a  chronic  character 
from  the  onset ;  in  these  circumstances  any  delay  in 
operating  may  diminish  the  chance  of  success. 

From  what  we  know  of  the  pathogenesis  and  evolu- 
tion of  an  ulcer  some  interesting  data  may  be 
obtained.  Thus  is  to  be  noted  a  remark  made  by 
numerous  clinicians,  namely,  that  rebellious  chronic 
ulcers  are  more  frequent  in  males  than  in  females. 
This  is  an  indication  that  one  must  not  continue 
treatment  too  long,  and  consequently  lose  an 


156  SUKGICAL  TREATMENT 

opportunity  that  is  often  invaluable.  Likewise  in 
young  subjects  the  ulcer  generally  takes  on  a  rapid 
evolution  with  little  tendency  to  chronicity  ;  on  the 
contrary,  in  older  individuals  chronic  ulcer  is  the 
almost  invariable  rule ;  therefore  not  so  much  can 
be  expected  from  medical  treatment  in  the  latter. 

Finally,  the  localisation  of  the  ulcer  appears  to  play  a 
part.  The  site  of  the  ulcer  has  been  said  to  be  difficult 
to  locate,  but  this  is  possible  to  do,  although  with 
less  probability,  by  basing  the  diagnosis  on  the  painful 
radiations  and  the  more  or  less  tardy  appearance  of 
pain  after  eating,  as  well  as  the  localisation  of  pain  on 
pressure  over  the  various  epigastric  areas. 

Pyloric  or  prepyloric  ulcer  is  not  only  more 
tenacious,  especially  on  account  of  the  spasm  it 
produces,  but  also  has  great  chances  of  leaving  traces 
of  its  presence  after  a  cure  has  been  effected,  which 
at  a  more  remote  date  will  require  operation.  The 
slower  and  the  more  chronic  the  evolution,  the  greater 
will  be  the  risk  of  stenosing  cicatrisation.  Therefore 
there  will  be  advantage  in  not  prolonging  medical 
treatment  of  ulcers  of  the  pylorus  and  prepyloric  area  to 
any  great  extent,  while  there  will  be  less  disadvantage 
in  continuing  it  with  more  patience  in  cases  of  the  body 
of  the  stomach  and  those  of  the  greater  curvature. 

As  to  ulcers  of  the  lesser  curvature,  they  are,  we 
might  say,  intermediary  between  these  two  classes ; 
they  have,  in  fact,  a  manifest  tendency  to  extend  in 
the  direction  of  the  pylorus,  and  for  this  reason  have 
more  analogy  with  the  latter. 

The  pyloric  localisation  of  the  ulcer  is  important, 
not  only  because  of  the  ulterior  complications  to 


TYPICAL  GASTRIC  ULCER  157 

which  its  healing  may  give  rise — such  as  cicatricial 
stenosis — but  in  a  lesser  degree  because  of  the  spasm 
it  provokes.  This  does  not  imply  that  pyloric  spasm 
is  only  due  to  ulcers  in  the  neighbourhood  of  the 
sphincter,  because  cases  are  well  known  where  an 
ulcer  seated  in  some  part  of  the  stomach  distant 
from  the  pylorus  has  given  rise  to  spasm  ;  neverthe- 
less, the  nearer  an  ulcer  is  seated  to  the  pylorus,  the 
greater  will  be  the  chances  of  spasm. 

As  we  have  seen,  spasm  forms  with  ulcer  a  true 
vicious  circle  ;  the  latter  provokes  the  former,  and 
the  spasm  prevents  the  cure  of  the  ulcer.  The  greater 
risk  of  an  ulcer  accompanied  by  spasm  passing  to 
the  chronic  state  should  be  an  encouragement  not 
to  persist  too  long  with  medical  treatment  when  this 
aggravating  circumstance  is  manifest. 

In  these  difficult  cases  operative  treatment  gives, 
on  the  contrary,  very  good  results,  since  it  abolishes 
either  the  origin  of  the  spastic  reflex  or  the  stenosis 
and  gastric  retention,  according  to  the  procedure 
employed. 

Hence  the  treatment  of  typical  ulcer  without  any 
predominating  symptom  should  be  essentially  medical 
at  the  onset  when  the  lesion  has  an  acute  evolution. 
The  duration  of  the  evolution  can  hardly  be  deter- 
mined beforehand,  and  therefore  is  subject  to  no  fixed 
rule.  When  the  ulcer  has  a  tendency  to  pass  to  the 
chronic  state,  or  certain  circumstances,  such  as  the  age 
or  sex  of  the  patient,  the  site  of  the  ulcer  or  spasm  of 
the  pylorus,  cause  one  to  suspect  this  evolution,  the 
possibility  of  an  interference  must  be  seriously  envi- 
saged, and  it  should  not  be  delayed  until  the  time 


158  SUEGICAL  TREATMENT 

when  the  general  weakness  or  the  development  of  a 
complication  or  reaction  on  the  general  gastric  state 
obliges  the  surgeon  to  act.  If  the  appearance  of  this 
indication  for  operation  is  awaited  before  the  opera- 
tive act  is  undertaken,  not  only  will  the  immediate 
dangers  be  greater,  but  it  should  be  recalled  that 
operation  done  in  these  circumstances  has  a  functional 
prognosis  infinitely  less  encouraging  than  if  the 
operation  had  been  undertaken  sooner. 

Does  operative  treatment  assure  a  cure  in  all  cases, 
or  even  is  it  successful  in  cases  where  nothing  was 
gained  by  medical  treatment  ?  Some  writers,  on  the 
contrary,  admit  that  had  medical  treatment  been 
continued  sufficiently  long  the  ultimate  success  would 
be  quite  as  great.  According  to  their  view-point, 
recurrences  of  ulcers  and  the  serious  haemorrhages  are 
encountered  as  much  after  the  operation  as  after 
proper  medical  treatment.  However,  they  also 
admit  that  operation  presents  great  advantages  in 
cases  which  are  accompanied  by  pyloric  stenosis. 
With  the  exception  of  these  cases,  in  ordinary  ulcer, 
such  as  we  are  considering  in  this  chapter,  they  believe 
that  an  operation  will  be  devoid  of  any  influence. 

Although  this  opinion  could  have  been  upheld  with 
some  semblance  of  reason  some  few  years  ago,  at  a 
time  when  the  operative  treatment  of  ulcer  was  still 
in  its  infancy,  the  details  now  in  our  possession  in 
regard  to  the  results  of  this  treatment  completely 
refute  as  erroneous  this  supposition.  It  is  easy  to 
become  convinced  if  one  will  refer  to  the  more 
important  statistics,  and  particularly  those  which 
include  the  remote  results,  the  only  ones  of  any  value 


TYPICAL  GASTRIC  ULCER  159 

whatsoever.  It  will  be  seen  that,  although  for  many 
writers  the  influence  of  the  operation  remains 
unexplained,  such  an  influence  is  real  and  undeniable. 
Does  this  imply  that  operative  treatment  only 
brings  success  ?  We  are  far  from  wishing  to  convey 
such  an  idea  ;  on  the  contrary,  one  should  always 
anticipate  a  certain  percentage  of  failures  due  to 
various  causes.  These  failures  are  either  immediate 
or  remote.  Among  the  former  the  operative  mor- 
tality, that  some  writers  consider  to  be  very  high,  is 
one  of  the  great  arguments  against  surgical  treatment. 
Operative  mortality,  so  high  not  many  years  since, 
has  become  progressively  lowered,  and  at  the  present 
time  has  reached  a  minimum  rate.  It  nevertheless 
persists,  varying  from  one  surgeon  to  another,  with 
the  nature  of  the  surgical  act,  and,  above  all,  with 
the  condition  of  the  patients  at  the  time  they  were 
subjected  to  it.  Hence  we  even  find  quite  consi- 
derable differences  in  the  following  statistics  : — 

Czerny  (1902),  9-5  per  cent. 

Von  Eiselsberg  (1905),  25  per  cent. 

Moynihan  (1905),  1-8  per  cent.;   total  number 
of  cases,  155. 

Kroenlein  (1906),  18-8  per  cent. 

Mikulicz  (1906),  35  per  cent,  before  1891,  18-7 
per  cent,  since  that  year. 

Graf  (1907),  4  per  cent. 

Hildebrandt   (1907),  8  per  cent.,  due  to  bad 
condition  of  patients. 

Mayo-Robson  (1908),  5  per  cent,  including  all 

cases,  1-1  per  cent,  excluding  perforations. 
We  could  still  append  a  long  list  of  statistics,  but 


160  SURGICAL  TREATMENT 

it  would  not  offer  much  of  any  interest.  Let  it 
merely  be  said  that  an  average  of  7  per  cent,  mortality 
will  fairly  well  indicate  the  operative  loss  for  the  past 
fifteen  years.  This  only  comprises  cases  of  chronic 
ulcer  without  complications,  and  this  average  is  even 
too  high,  because  it  includes  all  cases  of  gastric  sur- 
gery in  general,  even  operations  for  perforation  and 
haemorrhage,  which  naturally  give  an  infinitely  greater 
percentage  of  failures. 

It  is  consequently  only  just  to  say,  apart  from 
certain  special  cases,  that  operations  for  chronic 
gastric  ulcer  should  not  be  regarded  as  serious,  or 
the  risk  so  great  that  they  should  only  be  con- 
sidered as  a  last  resource.  Quite  on  the  contrary, 
a  subject  with  chronic  ulcer  runs  less  risk,  we  believe, 
in  undergoing  operation  than  in  following  medical 
treatment,  which  leaves  him  at  the  mercy  of  serious 
complications.  These  may  arise  more  or  less 
remotely  after  the  onset  of  the  lesion  ;  they  may  even 
occur  following  a  period  of  manifest  amelioration, 
sometimes  prolonged ;  but  they  are  met  with  in 
30  per  cent,  of  the  cases  according  to  Mikulicz,  and 
in  25  per  cent,  according  to  Kroenlein.  We  are, 
therefore,  far  from  the  7  per  cent,  average  that  we 
have  given,  a  proportion,  we  repeat,  that  is  unques- 
tionably too  high. 

As  to  the  remote  results,  are  they  sufficiently 
assured,  so  that  one  may  predict  with  certainty  that 
a  radical  recovery  has  taken  place,  so  that  the  patient 
is  surely  protected  against  these  tardy  complica- 
tions ?  This  would  be  difficult  to  maintain  :  there 
always  remains  a  percentage  of  rebellious  cases,  over 


TYPICAL  GASTEIC  ULCER  161 

which  operation  is  devoid  of  influence,  or,  at  least, 
the  influence  is  only  temporary  or  incomplete. 
These  cases  are  usually  those  where  medical  treat- 
ment has  been  followed  for  a  very  long  time,  often 
not  in  a  sufficiently  regular  or  strict  fashion,  so  that 
the  ulcer  has  been  allowed  to  assume  a  particularly 
malignant  form,  which  has  profoundly  reacted  on  the 
general  health. 

We  have  already  said  when  speaking  of  pyloric 
stenosis,  and  we  do  not  hesitate  to  again  repeat,  that 
these  bad  results  are  largely  due  to  the  long  duration 
of  an  incomplete  medical  treatment.  The  encourag- 
ing results  of  gastric  surgery  will  be  sensibly  improved 
when  the  day  comes  when  patients  will  not  wait  until 
the  last  minute  to  be  operated  on. 

At  the  present  time  the  results  obtained  clearly 
show  the  real  unquestioned  influence  of  operative 
treatment.  Thus,  if  we  again  resort  to  statistical 
findings  published  during  the  past  few  years,  it  will 
be  found  that,  in  a  general  way,  operations  for  gastric 
ulcer  give  the  following  percentages : — 

Not 

Cured.           Improved,      benefited. 
Per  cent.         Per  cent.        Per  cent. 

Cramer  (1906)     ..  ..54  37-5          7-8 

Schulz(1907)      ..  ..     66-6  23  10-4 

Hildebrandt  (1907)  . .     61  24  15 

Mayo-Robson  (1908)  . .     90  5  5 

Eiselsberg  (1900)  . .     62 

Hartmann  (1905)  . .     90  10  0 

Jonnesco  (1905)..  ..90  10  0 

Gelston  Atkins  (1906)  . .     93  7  0 

W.  D.  Haines  (1918)  . .     50  30  15—20 


162  SURGICAL   TREATMENT 

The  recent  statistics  of  Troell,  published  in  1917, 
show  that  of  234  chronic  ulcers  operated  on  in  the 
Seraphim  Hospital  at  Stockholm  during  the  years 
1907 — 1914  76  per  cent,  were  gastric  and  24  per  cent. 
duodenal.  A  comparison  between  operations  before 
and  after  1907  proves  that  palliative  operations  have 
to  a  considerable  extent  been  superseded  by  more 
radical  procedures.  Thus  previous  to  1907  pyloro- 
plasty  was  carried  out  in  more  than  4  per  cent,  of 
cases,  after  1907  scarcely  0-5  per  cent.  The  figures 
for  gastroenterostomy  were  60  per  cent,  and  44  per 
cent,  respectively.  The  proportion  of  6  per  cent,  and 
0-5  per  cent,  respectively  for  enteroanastomosis 
indicates  that  anterior  gastroenterostomy  has  been 
replaced  more  and  more  by  the  posterior  proce- 
dure. A  corresponding  increase  is  also  noted  con- 
cerning the  radical  procedures  in  the  treatment  of 
gastric  ulcer.  In  the  first  series  segmentary  resec- 
tion with  or  without  gastroenterostomy  has  been  done 
in  scarcely  5  per  cent,  of  the  cases ;  in  the  second,  in 
10  per  cent.  Pylorectomy  with  gastroenterostomy 
has  increased  from  5  per  cent,  to  26  per  cent. 

The  primary  mortality  from  operations  shows  a 
decline  from  8 '5  per  cent,  to  6  per  cent,  during  these 
periods  for  the  entire  series  operated  on,  from 
4«5  per  cent,  to  scarcely  2  per  cent,  for  gastro- 
enterostomy, and  from  20  per  cent,  to  8  per  cent. 
for  pylorectomy  with  gastroenterostomy.  For  ulcer 
excision  without  gastroenterostomy  the  death-rate 
is  remarkably  high,  being  67  per  cent,  and  33  per 
cent,  respectively,  and  nil  in  excision  of  the  ulcer  with 
gastroenterostomy. 


TYPICAL  GASTRIC  ULCER  163 

The  end  results  in  from  one  to  nine  years  after 
operation — 12  per  cent,  of  the  patients  did  not 
return  for  examination — show  that  of  the  entire 
number  70  per  cent,  are  still  alive  and  have  fully 
recovered  or  improved,  while  12  per  cent,  had  to 
submit  to  a  new  operation,  and  3-5  per  cent,  had 
died  of  gastric  diseases.  The  corresponding  figures 
for  the  total  conservative  operations  are  66  per  cent., 
14  per  cent,  and  3  per  cent,  respectively.  Calculated 
only  in  regard  to  the  usual  procedures,  gastroenteros- 
tomy  and  pylorectomy  and  gastroenterostomy  only, 
the  figures  obtained  are  68  per  cent.,  12  per  cent,  and 
2  per  cent,  and  83  per  cent.,  5  per  cent,  and  2  per 
cent,  respectively  for  those  patients  who  survived  any 
length  of  time.  Of  the  total  number  of  patients 
subjected  to  gastroenterostomy  66  per  cent,  recovered 
or  improved,  while  the  cases  of  pylorectomy  and 
gastroenterostomy  recovered  or  improved  in  77  per 
cent.  Recurrence  of  symptoms  subsequently  to 
interference  for  ulcer  in  many  cases  unquestionably 
depends  to  a  considerable  degree  on  the  surgeon's 
neglecting  to  give  suitable  diet  and  other  prescrip- 
tions to  be  followed  after  recovery  from  the  operative 
act. 

To  prove  the  illogical  practice  of  operating  on  simple 
uncomplicated  gastric  ulcer  we  need  only  refer  to 
Udadono's  recent  statistics  (1918).  He  reports  the 
end  results  in  twenty-two  out  of  seventy-one  opera- 
tions for  "  uncomplicated  "  ulcer  followed  for  one 
to  four  years.  Only  27-24  per  cent,  are  free  from 
disturbances.  All  the  others  have  had  the  old 
subjective  symptoms  return  as  severe  as  before  the 

M   2 


164  SUEGICAL  TREATMENT 

operation  and  quite  as  rebellious.  The  symptoms 
returned  after  intervals  varying  from  three  months 
to  two  years,  the  average  being  six  to  ten  months. 
There  has  been  haematemesis  in  16  per  cent,  and 
occult  blood  in  over  86  per  cent.  The  stomata  seem 
to  be  working  well  in  all.  In  only  one  is  there  a 
suspicion  of  syphilis,  and  there  is  nothing  to  suggest 
jejunal  ulceration  in  any  case.  Such  depressing 
statistics  are  the  evident  result  of  meddlesome  surgery 
in  cases  suitable  for  medical  treatment. 

It  is  therefore  apparent  that  surgical  treatment 
often  gives  unhoped-for  results  in  cases  of  ulcer 
whose  previous  long  evolution  had  resisted  all  kinds 
of  medical  treatment.  In  reality  failures  are  few, 
likewise  the  semi-successful  results  when  compared 
with  permanent  complete  recoveries. 

In  what  way  do  these  various  surgical  procedures 
act  in  such  a  constant  fashion  to  give  such  good 
results  ?  This  is  a  question  that  has  often  been  raised, 
and  to  solve  it  writers  have  searched  for  the  intimate 
action  of  operations  on  the  gastric  functions.  From 
these  researches  it  results  that  surgical  treatment  is 
not  empirical,  as  many  have  been  led  to  suspect,  and 
as  might  have  been  supposed  in  the  early  days  of 
gastric  surgery,  but,  on  the  contrary,  it  is  rational, 
and  its  action  is  perfectly  clear.  In  a  word,  it  can 
at  present  be  said  that  the  operation  essentially 
complies  with  the  accepted  data  of  pathogenesis. 
Let  us  briefly  here  recall  the  principal  points  of  the 
pathogenesis  of  gastric  ulcer  ;  this  will  allow  the 
better  understanding  of  the  intimate  action  of  the 
surgical  treatment  of  the  lesion. 


TYPICAL  GASTRIC  ULCER  165 

In  a  preceding  chapter  we  pointed  out  that  the 
concourse  of  several  circumstances  was  necessary  for 
the  development  of  an  ulcer.  Of  this  concourse  of 
pathogenic  factors  some  are  variable  according  to 
the  case,  but  only  possess  an  effective  action  when 
they  are  associated  with  a  factor  which  is  not  always 
present,  namely,  hyperacidity  of  the  gastric  secretion. 
Not  only  is  hyperacidity  of  the  gastric  juice  the 
primordial  factor  in  the  foundation  of  the  lesion,  but 
also  the  persistence  of  this  action  influences  the 
evolution  of  the  process,  imparting  to  it  the  most 
serious  chronic  character. 

Hence  the  ulcer  is  the  consequence  of  a  change  in 
the  physiology  of  the  stomach  in  general  rather  than 
a  distinctly  localised  affection  of  a  limited  area  of  the 
mucosa.  And,  what  is  more,  when  once  the  ulcer 
has  formed  it  in  turn  acts  on  the  gastric  physiology 
either  in  keeping  up  the  hyperacidity  or  in  changing 
the  motor  functions. 

Seen  from  this  view-point,  the  pathogenesis  of 
gastric  ulcer  assumes  a  new  character,  and  the  action 
of  surgical  treatment  is  easily  explained  from  the  fact 
that  it  radically  modifies  this  profoundly  disturbed 
physiology.  In  fact,  it  influences  both  gastric 
chemism  and  motility  of  the  stomach. 

Influence  of  Operative  Treatment  on  Gastric 
Motility. — In  the  first  place,  it  is  necessary  to 
examine  how  the  gastric  motility  behaves  during 
the  evolution  of  ulcer.  In  the  great  majority  of 
cases,  as  numerous  statistics  demonstrate,  the  gastric 
motility  is  changed  in  variable  proportions,  but 
nevertheless  always  distinctly  appreciable.  In  the 


166  SURGICAL  TREATMENT 

majority  of  cases,  principally  chronic  ulcer,  pheno- 
mena of  stasis  are  observed.  The  stasis  is  not  always 
permanent ;  on  the  contrary,  it  is  frequently  transi- 
tory, the  periods  of  normal  motility  alternating  with 
periods  of  paresis  of  the  gastric  work.  The  latter 
occur  especially  during  the  acute  outbursts  of  the 
ulcer. 

The  causes  of  gastric  stasis  are  either  anatomical 
or  nervous.  The  former  are  periulcerous  tume- 
factions due  to  acute  inflammatory  outbursts  in 
the  ulcer  situated  near  the  pylorus  that  previous 
cicatricial  processes  have  already  changed  and 
partially  narrowed.  Now,  if  this  inflammatory 
attack  calms  down,  the  cellular  infiltration  and  con- 
gestion diminish,  and  consequently  the  tumefaction 
subsides,  leaving  the  pylorus  permeable  for  a  time  ; 
the  stasis  therefore  disappears.  But  at  the  same 
time,  as  we  shall  show,  the  stasis  acts  on  the  ulcer, 
keeping  it  up,  so  to  speak,  and  as  the  attacks  are 
repeated,  they  become  progressively  more  serious, 
and  the  stasis,  at  first  transitory,  tends  to  become 
permanent. 

Among  the  nervous  factors  of  stasis  spasm  should 
be  mentioned  in  the  first  place.  P}doric  spasm  is 
extremely  frequent  during  the  evolution  of  ulcer. 
It  is  even  often  associated  with  the  tumefaction 
referred  to ;  hence  the  two  factors,  anatomical  and 
nervous,  become  combined.  The  spasm  due  to  ulcer 
is  the  result  of  a  reflex  provoked  by  irritation  of  the 
lesion.  Thus  are  explained  the  phenomena  of  stasis 
provoked  by  an  ulcer  on  the  posterior  gastric  wall, 
which  anatomically  can  have  no  influence  on  gastric 


TYPICAL  GASTRIC  ULCER  167 

transit.  This  reflex  stasis  is,  even  more  than  the 
stasis  due  to  the  anatomical  lesion,  variable  and 
transitory.  However,  like  it,  it  is  related  to  the  acute 
outbursts  of  the  ulcer,  and  exercises  the  same  influence 
on  the  lesion. 

How  much  importance  should  be  attributed  to  the 
stasis  which  is  often  slight  and  intermittent  ?  It  acts 
in  various  ways  on  the  stomach,  but  it  must  be  re- 
cognised that  its  action  is  far  from  favourable  on  the 
lesion.  In  the  first  place,  from  the  obstacle  to  evacua- 
tion that  it  occasions,  it  forces  the  organ  to  perform 
exaggerated  work ;  therefore  it  provokes  an  all  the 
more  energetic  peristaltic  action,  since  we  know  that 
the  ulcer  only  occurs  in  hypers thenic  stomachs.  As 
much  from  the  chemical  as  from  the  muscular  view- 
point, this  exaggerated  peristalsis  is  far  from  being 
favourable,  as  can  be  readily  conceived,  for  the 
evolution  of  an  ulcer,  on  account  of  the  irritation  that 
it  causes,  as  well  as  the  congested  state  in  which  it 
maintains  the  gastric  walls. 

From  the  long  sojourn  of  the  food,  it  also  favours 
irritation  not  only  of  the  ulcer,  but  also  of  the  gastric 
mucosa,  a  condition  of  affairs  that  is  far  from 
indifferent.  Not  to  speak  of  secondary  fermentation 
resulting  from  this  long  sojourn  of  the  food  in  the 
stomach,  fermentation  which  is  hardly  ever  wanting, 
the  gastric  contents  from  their  mere  prolonged 
contact  with  the  mucosa  produce  an  irritation  and 
permanent  congestion  which  can  only  be  nefarious. 

Stasis  still  acts  in  a  third  fashion.  The  researches 
of  Carle  and  Fantino  and  those  of  Doyen,  as  well 
as  subsequent  observers,  have  shown  that  stasis 


168  SURGICAL  TREATMENT 

favours  hypersecretion  and  hyperchlorhydria  in  a 
most  striking  way.  In  the  vast  majority  of  cases 
it  is  no  longer  the  hyperchlorhydria  which  provokes 
the  spasm,  hence  the  stasis,  but  it  is  the  stasis  that 
favours  the  hyperchlorhydria.  This  is  unquestion- 
ably one  of  the  most  unfavourable  actions  that  stasis 
can  exert  in  regard  to  the  ulterior  evolution  of  the 
lesion,  as  we  pointed  out  when  speaking  of  the 
pathogenesis. 

Consequently,  to  briefly  sum  up,  it  will  be  seen  that 
permanent,  or  even  transitory,  stasis  has  as  conse- 
quences : — 

(1)  To  provoke  increased  peristalsis ; 

(2)  To  keep  up  a  permanent  state  of  congestion  of 
the  mucosa  ; 

(3)  To  incite  the  mucosa  to  an  exaggerated  secre- 
tion of  hydrochloric  acid,  which  all  have  a  nefarious 
action  on  the  evolution  of  the  ulcer. 

It  is  consequently  natural  that  a  treatment  which 
will  finally  overcome  the  stasis  will,  from  this  very 
fact,  exert  an  energetic  favourable  action  on  the  lesion. 
This  action  will  not  always  be  direct — far  from  it — 
it  is,  nevertheless,  by  it  that  the  good  results  obtained 
by  operations  which  do  not  directly  deal  with  the  ulcer 
are  to  be  explained.  The  various  procedures  directed 
against  the  ulcer  do  not  all  act  in  the  same  fashion ; 
the  majority,  however,  ameliorate  the  gastric  motility. 
When  speaking  of  the  choice  of  procedure  we  shall 
show  that  certain  operations  assure  a  better  evacua- 
tion of  the  stomach  than  others,  so  we  will  not  con- 
sider the  subject  further. 

Naturally  each  and  every  procedure  cannot  have 


TYPICAL  GASTRIC  ULCER  169 

the  same  effectiveness.  Some,  like  gastroenteros- 
tomy,  have  as  chief  object  to  assure  a  rapid  outflow 
of  the  gastric  contents ;  and,  according  to  many 
writers,  this  is  their  only  action.  Other  procedures, 
such  as  simple  excision  of  an  ulcer  seated  some 
distance  from  the  pylorus,  are  not  intended  to  over- 
come stasis.  However,  the  latter  have  an  unquestion- 
able influence,  which  is  explained  by  the  fact  that  by 
eliminating  the  ulcer  the  starting-point  of  the  reflexes 
causing  pyloric  spasm  is  suppressed,  hence  the 
transitory  stasis. 

Let  us  say  at  once  that  these  procedures  are  too 
indirect  to  give  constant  and  regular  results,  such  as 
are  obtained  from  gastroenterostomy  or  pylorectomy. 
But  even  gastroenterostomy  does  not  always  give 
regular  results,  especially  permanent  ones,  in  cases  of 
ulcer  in  activity  unaccompanied  by  true,  fixed  pyloric 
stenosis. 

In  cases  of  transitory  stasis,  especially  where 
this  is  due  to  spasm,  as  soon  as  the  operation  shall 
have  produced  its  first  effect,  when  it  shall  have 
resulted  in  effective  evacuation  of  the  stomach,  the 
spasm  will  diminish,  and  the  gastric  contents  will 
pass  through  the  now  patent  pylorus.  We  have  seen 
what  destiny  awaits  anastomosis  in  cases  of  per- 
meability of  the  pylorus  :  not  being  utilised,  the 
stoma  is  not  long  in  closing,  or  at  least  contracts  in  a 
large  measure.  Now,  if  spasm  should  recur,  the  stoma 
may  not  functionate  any  longer,  so  that  the  stomach 
finds  itself  in  the  same  anatomical  conditions  as  before 
the  interference. 

Functional  examinations  undertaken  several  years 


170  SURGICAL   TREATMENT 

after  operation,  in  fact,  show  clearly  that  gastro- 
enterostomy  only  overcomes  the  stasis  momentarily 
when  the  pylorus  remains  patent.  When,  on  the 
contrary,  the  pylorus  is  stenosed  from  cicatricial  con- 
traction or  artificially  by  Billroth's  pylorectomy  II. 
or  an  exclusion,  the  improvement  in  the  pyloric 
transit  noted  during  the  first  weeks  following  the 
operation  will  be  regular  and  will  last  for  a  period  of 
time  sufficiently  prolonged  so  that  this  result  can  be 
regarded  as  definite. 

Neuhaus'  verifications  are  particularly  interesting 
in  this  respect,  and  similar  examples  have  become 
progressively  frequent  since  Quenu  and  Tuffier 
called  the  attention  of  surgeons  to  the  illusive 
functions  of  gastroenterostomy  in  stomachs  with  a 
patent  pylorus.  We  would  merely  remark  that 
Kelling  had  already  carried  out  conclusive  experi- 
ments, confirmed  by  the  more  recent  ones  due  to 
Delbet,  which  should  not  have  been  allowed  to  escape 
notice. 

It  would,  therefore,  be  interesting  to  carry  out 
repeated  examinations  of  the  gastric  motility  for 
some  time  after  operation.  By  so  doing  one  will 
become  convinced  that  the  disappearance  of  the 
stasis  is  only  too  often  temporary  when  the  pylorus 
is  patent.  We  shall  show  further  on  that  it  is  here 
that  the  cause  should  be  looked  for  in  a  fairly  large 
proportion  of  recurrences  of  the  ulcer  or  partially 
successful  results.  This  is  all  the  more  important 
because  we  have  a  simple  and  sure  means  of  over- 
coming these  results. 

Influence  of  the  Operation  on  Gastric  Chemism. — 


TYPICAL  GASTRIC  ULCER  171 

The  researches  into  the  changes  which  various  gastric 
operations  bring  about  in  gastric  chemism  have  been 
almost  entirely  confined  to  that  occurring  after 
gastroenterostomy.  It  has  been  only  little  by  little 
that  a  control  of  the  functional  results  derived  from 
other  procedures  has  been  undertaken,  such  as 
pylorectomy,  resection  of  the  pylorus  and  excision  of 
the  ulcer.  In  order  to  understand  the  action  of  sur- 
gical treatment  on  gastric  chemism,  we  would  briefly 
recall  that  this  is  always  hyperactive. 

The  operations  have  in  a  general  way,  as  a  first 
result,  to  diminish  this  hyperacidity  almost  con- 
stantly. Although  these  procedures  attain  the  same 
end,  they  do  so  by  different  routes,  and  evidence  of 
their  effect  is  unequally  marked.  The  surgical  treat- 
ment may,  therefore,  act  in  different  ways,  according 
to  the  procedure  employed.  These  various  methods 
are  : — 

Abolition  of  the  stasis. 

Resection  of  the  ulcer,  hence  abolition  of  the 
starting-point  of  the  important  secretory  reflexes. 

The  arrival  of  the  alkaline  secretions,  pancreatic 
and  biliary,  which  combine  after  disappearance  of 
the  stasis. 

If  one  wishes  to  form  an  idea  of  the  effect  of  aboli- 
tion of  the  stasis  on  the  gastric  chemism,  one  cannot 
do  better  than  study  the  functional  results  derived 
from  Heinecke-Mikulicz  pyloroplasty.  This  pro- 
cedure was  devised  to  assure  a  better  evacuation  of 
the  stomach,  but  without  creating  a  new  gastro- 
intestinal stoma,  which  might,  as  in  gastroenteros- 
tomy, exercise  in  another  way  a  complex  action  on 


172  SUKGICAL  TREATMENT 

gastric  hyperacidity.  We  here  have  clinical  results 
which  are  in  reality  true  experiments.  Therefore 
let  us  see  to  what  extent  the  gastric  secretions  are 
influenced  by  the  operation  ;  in  this  way  we  shall  be 
informed  as  to  the  importance  of  overcoming  stasis. 

The  hyperacidity  decreases,  so  to  speak,  in  an 
almost  constant  fashion  after  pyloroplasty  in  a  pro- 
portion that  may  be  evaluated,  according  to  Kausch, 
at  about  80  per  cent.  The  cases  are  divided  as 
follows : 

Before  operation. 

Five  cases  with  HC1  highly  increased. 

Nine  cases  with  medium  increase  of  HC1. 

Five  cases  with  normal  HC1. 
After  operation. 

Three  cases  with  slightly  increased  HC1. 

Eleven  cases  with  HC1  normal. 

Two  cases  with  diminished  HC1. 
It  is  difficult  to  form  an  exact  idea  of  the  part 
played  by  excision  of  the  ulcer.  Rare,  in  fact,  are 
those  operations  which  merely  consist  of  excision  of 
the  lesion  without  at  the  same  time  changing  the 
gastric  motility.  The  majority  of  excisions  of  ulcer 
are  either  pylorectomies  or  annular  resections,  con- 
sequently operations  with  a  double  end  to  attain 
and  a  double  effect. 

We,  therefore,  cannot,  on  account  of  an  insufficient 
number  of  clinical  results,  form  an  exact  opinion,  and 
all  we  can  do  is  to  consider  the  results  of  experimental 
work,  such  as  that  carried  out  by  Pawlow.  This 
observer  has  demonstrated  the  influence  of  experi- 
mental ulcer  on  the  production  of  hyperacidity,  a 


TYPICAL  GASTRIC  ULCER  173 

demonstration  that  may  be,  in  a  way,  inverted,  and 
lead  one  to  admit  that  excision  of  the  ulcer,  by 
suppressing  important  reflexes,  has  as  a  consequence 
the  diminution  of  the  hyperacidity  due  to  ulcer  in 
rather  notable  proportions. 

But  we  would  repeat,  these  are  practically  only 
theoretical  views,  clinical  examinations  not  having 
been  sufficiently  numerous  to  give  conclusive  data. 

Therefore  it  is  evident  that  abolition  of  the  stasis 
on  the  one  hand,  and  the  suppression  of  the  starting- 
point  of  the  reflexes  on  the  other,  in  themselves 
already  decrease  the  acidity  of  the  gastric  chemism. 
The  reunion  of  these  two  causes,  acting  simultane- 
ously, as  in  certain  pylorectomies  or  annular  resections, 
gives  still  more  distinct  and  conclusive  results.  Hence 
in  the  majority  of  cases  of  pylorectomy  with  direct 
gastro-duodenal  union — that  is  to  say,  carried  out  by 
any  technique  excepting  Billroth's  II. — it  will  be 
found  that  the  hyperacid  chemism  will  have  become 
either  normal  or  even  hypoacid.  Lastly,  the  diminu- 
tion of  the  hyperacidity  is  also  explained  by  the  fact 
that  according  to  the  technique  employed — gastro- 
enterostomy  in  particular — the  alkaline  secretions  of 
the  duodenum  neutralise  the  gastric  juice. 

The  great  majority  of  examinations  of  gastric 
chemism  following  gastroenterostomy  have  demon- 
strated the  presence  of  bile  and  pancreatic  juice  in 
the  stomach.  This  discovery  was  even  considered  at 
first  as  one  of  the  disadvantages  of  this  operation. 
It  was  asked,  not  without  disquiet,  to  what  extent 
these  strongly  alkaline  secretions  might  interfere 
with  gastric  digestion. 


174  SURGICAL  TREATMENT 

The  action  of  the  bile  was  known  ;  the  then  few 
operations  of  cholecystogastrostomy  had  demon- 
strated its  harmlessness ;  the  pancreatic  juice,  less 
well  known,  might  have,  it  was  thought,  a  more 
energetic  action  which  would  be  harmful. 

Experience,  however,  demonstrated  that  the  pan- 
creatic juice,  like  the  bile,  did  not  exert  any  nefarious 
influence  on  gastric  digestion.  On  the  contrary,  as 
the  pathogenesis  of  ulcer  became  better  understood 
and  the  important  part  played  by  hyperchlorhydria 
became  recognised,  the  reflux — automatic,  so  to 
speak — of  these  alkaline  secretions  was  more  and 
more  desired.  It  is  for  this  reason  that,  among  the 
techniques  of  gastroenterostomy,  those  which  pre- 
vent the  reflux  have  been  discarded,  such,  for 
example,  as  Roux's  Y  gastroenterostomy. 

It  is  natural  that  the  diminution  of  hyperacidity 
following  gastroenterostomy  does  not  solely  depend 
upon  this  cause.  Here  again  we  find  the  combined 
action  of  the  two  simultaneous  causes,  namely,  the 
suppression  of  the  stasis  and  reflux  of  alkaline  fluid. 
To  ascertain  the  part  played  by  each  is  impossible, 
but  this  is  unimportant.  However,  it  can  be  said 
that,  in  a  general  way,  the  effect  of  gastroenterostomy 
is  to  reduce  the  gastric  acidity  to  normal  percentage, 
or  even  below  the  normal. 

Finally,  in  pylorectomies  by  Billroth's  procedure  II. 
the  three  causes  are  combined,  namely,  ablation  of 
the  ulcer,  abolition  of  the  stasis  and,  lastly,  direct 
neutralisation  by  retrograde  flux  of  the  alkaline 
secretions.  It  is  probably  for  these  reasons  that  the 
partisans  of  this  method  prefer  it  to  all  others,  main- 


TYPICAL  GASTRIC  ULCER  175 

taining  that  this  operation  results  in  a  more  rapid, 
more  marked  and  also  a  more  constant  diminution  of 
the  hyperacidity  than  all  other  procedures  resorted 
to  for  gastric  ulcer.  Hence,  no  matter  what  operative 
procedure  is  employed,  the  first  result  to  be  attained 
is  a  diminution  of  the  hyperacidity. 

As  we  have  already  remarked,  the  primordial 
pathogenic  factor  of  ulcer  is  hyperacidity.  This 
action  of  the  operative  treatment  is  consequently  the 
most  important,  since  with  hyperacidity  the  requisite 
condition  for  the  appearance  and  development  of 
the  lesion  disappears.  The  other  causes  of  ulcer  are 
numerous  and  variable,  and  for  the  most  part  escape 
modern  means  of  treatment,  but  we  have  pointed 
out  that  they  are  secondary,  and  without  hyperacidity 
they  cannot  produce  the  lesion. 

It  is  for  this  reason  that  we  believe  that  surgical 
treatment,  as  Katzenstein  has  shown,  is  logical 
and  rational,  causal  and  not  empirical.  Several 
writers,  Fibich  and  Katzenstein  among  others,  have 
attempted  to  prove  experimentally  that  gastro- 
enterostomy  really  exerts  an  influence  on  the  de- 
velopment of  ulcer.  Their  experiments  were  carried 
out  on  dogs,  in  which  they  produced  gastric  ulcer  by 
various  means,  such  as  excision  of  the  mucosa  and 
cauterisation  with  hydrochloric  acid  ;  then  at  once 
or  after  an  interval  of  varying  length  of  time  gastro- 
enterostomy  was  done.  Autopsy  done  some  time 
afterward  showed  that  in  the  first  case  no  ulcer 
developed,  while  when  gastroenterostomy  was  done 
later  the  lesion  cicatrised  quickly,  while  in  the 
control  animals  the  ulcer  continued  to  develop 


176  SUEGICAL  TEEATMENT 

and  underwent  cicatrisation  with  much  greater 
slowness. 

What  do  these  experiments  teach  ?  In  our  opinion 
they  simply  show  that  gastroenterostomy  certainly 
has  a  favourable  influence  on  the  ulcer,  but  it  is 
hardly  possible  to  assimilate  an  experimental  ulcer 
with  Cruveilhier's  round  ulcer.  This  lesion,  as  wo 
have  seen,  has  not  as  yet  been  artificially  reproduced 
with  the  characters  of  the  clinical  type,  so  that  not 
much  importance  can  be  attached  to  these  experi- 
ments. They  do  not  give  absolutely  conclusive  data 
in  regard  to  the  action  of  operations  on  the  ulcer,  and 
especially  on  chronic  ulcer. 

These  experiments,  therefore,  seem  to  show,  even 
without  comparing  the  experimental  ulcer  with  the 
clinical  round  ulcer,  that  gastroenterostomy  exerts  a 
favourable  influence  on  cicatrisation  of  chronic  ulcer. 
They  certainly  seem  to  show  that  if  cicatrisation 
takes  place  more  quickly  it  is  due  to  the  decrease 
of  gastric  acidity  brought  about  by  it.  If  this 
influence  makes  itself  felt  even  on  the  digestive  action 
of  a  normal  stomach,  there  is  all  the  more  reason 
that  a  happy  effect  should  result  from  the  operation 
when,  from  a  disturbance  of  gastric  physiology,  the 
digestive  power  is  increased. 

The  operative  treatment  consequently  acts,  in  the 
first  place,  by  transforming  the  gastric  chemism, 
whose  exaggerated  digestive  power  it  diminishes.  It 
likewise  acts  by  regulating  the  motor  function,  thus 
facilitating  the  evacuation  of  the  stomach,  and, 
therefore,  diminishes  the  exaggerated  contraction  of 
the  gastric  walls  and  the  long,  irritating  sojourn  of 


TYPICAL  GASTRIC  ULCER  177 

the  gastric  contents.  But  this  action  cannot  be 
otherwise  than  slow,  and  one  must  not  expect  that 
operative  treatment  will  cure  an  ulcer  which  has  been 
present  for  several  years  in  the  space  of  a  few  weeks. 

We  will  even  go  further  in  this  idea,  in  that  we  do 
not  believe  that  an  operation,  especially  gastro- 
enterostomy,  itself  produces  a  cure  of  the  lesion.  Its 
part  is  confined  to  placing  the  stomach  in  such  a 
condition  that  it  will  allow  the  ulcer  to  cicatrise  by 
causing  a  real  transformation  of  the  gastric  physiology. 
The  favourable  conditions  for  the  formation,  and 
especially  the  development,  of  the  lesion  no  longer 
exist,  so  that  the  latter  can  be  properly  dealt  with  by 
medical  treatment.  We  say  can  be  because  we  main- 
tain that  post-operative  medical  treatment  is  one  of 
the  chief  points,  if  not  the  most  important  of  all, 
which  will  assure  the  effectiveness  of  the  surgical 
interference.  The  ulcer  is  not  modified  by  the  opera- 
tion; the  rest  of  the  gastric  mucosa  is  not  transformed, 
so  that  medical  treatment — and  this,  of  course, 
includes  diet — must  be  carried  out  which  before  the 
operation  was  rendered  nil  in  its  effects  on  account 
of  the  stasis  and  hyperacidity. 

It  is  only  relatively  recently  that  the  importance 
of  post-operative  medical  treatment  has  been  recog- 
nised ;  and  many  still  ignore  this  fact,  believing 
that,  operation  once  done,  the  patient  should  be  left 
to  his  own  devices.  In  fact,  the  patient  himself 
feels  well  and  appears  to  support  any  kind  of  food, 
and  for  this  reason  it  seems  useless  to  continue  diets 
that  fatigue  him  and  give  the  impression  that  the 
condition  of  affairs  has  not  been  improved. 

S.T.  N 


178  SURGICAL  TREATMENT 

The  patient  already  himself  has  too  great  a  ten- 
dency to  consider  the  temporary  improvement  which 
usually  ensues  as  a  final  cure.     Happy  to  be  rid  of  the 
yoke  of  diet  and  the  continued  medical  care  to  which 
he  has  been  submitted,  he  returns  to  his  former  mode 
of  life,  which  often  puts  his  stomach  to  a  rough  test. 
In  reality  the  surgeon  should  profit  by  the  period 
of  convalescence,  that  is  to  say  while  oversight  of  the 
patient  is  still  possible,  to  continue  the  diet,  which 
will  allow  the  ulcer  to  heal  completely  and  the  gastric 
mucosa  to  progressively  recover  its  normal  functions. 
The  length  of  time  that  this  control  of  the  patient 
should    be    exercised    cannot    be    indicated     even 
approximately,   because   each   case   will   require   a 
different  treatment  until  complete  recovery  has  been 
assured,  this  depending  upon  the  extent  of  the  lesion, 
the  susceptibility  of  the  mucosa  and  the  degree  of 
gastric  acidity. 

As  to  the  treatment  to  be  carried  out,  it  will  like- 
wise vary  according  to  the  case,  but  in  a  general  way 
it  should  be  that  of  an  acute  ulcer  at  its  onset.  Then, 
too,  in  order  to  facilitate  the  reflux  of  the  duodenal 
secretion,  a  diet  rich  in  fats  and  carbohydrates  should 
be  given  in  order  to  provoke  an  abundant  pancreatico- 
biliary  secretion.  We  have  already  insisted  too 
lengthily  on  the  importance  of  the  therapeutical 
action  of  these  alkaline  secretions  to  again  refer  to 
them.  Let  it  only  be  said  that  Katzenstein  was  the 
first  to  demonstrate  the  value  of  post-operative  diet, 
to  which  he  attributed  as  much  importance  as  the 
operation  itself,  and  in  this  we  heartily  concur. 

In  all  this  outline  we  have  had  gastroenterostomy 


TYPICAL  GASTRIC  ULCER  179 

principally  in  view.  We  shall  show  further  on  that 
this  operation  is  much  the  most  frequently  employed  ; 
but  before  examining  the  question  of  the  operation  of 
choice  we  will  offer  the  following  conclusions,  derived 
from  this  study  of  the  operative  treatment  of  ulcer  :— 

(1)  Operative  treatment  is  less   dangerous   than 
medical  treatment  when  the  process,  for  some  reason 
or  another,  tends  to  assume  a  chronic  evolution. 

(2)  The  results  of  operation  are  excellent  in  cases 
where  medical  treatment  has  failed. 

(3)  The  brilliant  results  so  far  attained  are  suscep- 
tible  of   being   still   further   improved  —  (1)   when 
operation  is  resorted  to  earlier  and  (2)  when   post- 
operative treatment  is  strictly  followed  for  a  sufficient 
length  of  time. 

Finally,  it  must  not  be  forgotten  that  before 
undertaking  an  operation  a  strict  medical  treatment 
should  be  essayed.  It  is  only  after  failure  of  the 
latter  that  operative  treatment  should  be  proposed, 
in  which  case  it  is  to  be  resorted  to  without  delay, 
otherwise  the  result  of  surgical  interference  will  be 
gravely  compromised. 

Choice  of  the  Procedure. — If  the  discussion  of  the 
indications  for  operation  in  gastric  ulcer  is  not  yet 
ready  to  close,  there  is  still  great  divergence  of  opinion 
as  to  the  procedure  to  be  employed  in  the  treatment 
of  ulcer  in  activity.  The  operations  to  choose  from 
are  : — 

Resections. 

Gastroenterostomy. 

Resection  and  gastroenterostomy. 

Jejunostomy  and  duodenostomy. 


180  SURGICAL  TREATMENT 

In  the  first  part  of  the  book  we  have  outlined  the 
technique  of  these  procedures,  so  that  it  now  only 
remains  to  examine  the  advantages  and  disadvantages 
of  each  in  particular. 

The  Resections. — These  were  the  first  procedures 
employed,  and  at  first  sight  might,  in  fact,  appear  to 
be  the  most  logical.  We  are  in  presence  of  an  ulcer 
which  cannot  heal  and  at  every  turn  of  the  road  may 
give  rise  to  fatal  hemorrhage  or  peritonitis  from 
perforation.  The  solution  of  the  problem  is  clear  : 
the  lesion  should  be  excised,  the  fresh  edges  of  the 
resulting  wound  sutured,  and  cicatrisation  of  the 
ulcer  will  ensue.  Unfortunately  the  problem  is 
infinitely  more  complex,  as  the  pathogenic  data  we 
possess  amply  demonstrate. 

Advantages  of  Resection. — For  the  partisans  of 
resection  of  the  ulcer  the  principal  advantages  of  the 
procedure  are  : — 

(1)  The    immediate    disappearance    of    an    ulcer 
always  on  the  point  of  perforating  or  giving  rise  to 
haemorrhage  of  a  serious  nature,  in  a  word  susceptible 
of  provoking  fatal  accidents  at  any  time. 

(2)  Almost  certainly  avoiding  cancerous  transfor- 
mation of  the  lesion. 

(3)  The  process  is  dealt  with  without  transforming 
the  gastric  physiology,  as  other  procedures  do,  at 
least  in  the  case  of  some  of  them. 

The  first  of  these  advantages  is  unquestionable. 
It  is,  in  fact,  incontestable  that  after  resection  the 
ulcer  cannot  give  rise  to  hemorrhage  or  perforation. 
Cicatrisation  of  an  operative  wound  of  the  stomach 
takes  place  quickly,  and  cannot  be  compared  with 


TYPICAL  GASTRIC  ULCER  181 

that  of  an  ulcer  even  when  the  lesion  is  undergoing 
rapid  healing. 

Malignant  transformation  of  gastric  ulcers  is  quite 
frequent  enough  to  give  the  argument  much  weight. 
Although  many  writers  are  far  from  agreement  in 
regard  to  the  relative  frequency  of  this  transforma- 
tion, the  figures  they  offer  vary  from  90  per  cent., 
60  per  cent,  and  10  per  cent,  of  cancer  grafted  on  old 
ulcers,  showing  that  this  occurrence  must  be  taken 
into  serious  consideration.  It  would  even  be  of 
capital  importance  if  the  teachings  of  the  Lyons 
school  were  accepted,  which  maintain  that  gastric 
ulcer  always  possesses  a  malignant  character.  But 
this  opinion  does  not  seem  to  be  at  present  tenable  : 
the  ulcer  is  not  primarily  cancerous,  but  presents 
sclerous  tissue  offering  a  propitious  soil  for  the 
development  of  malignant  tissue.  Hence,  if  this  be 
a  secondary  process,  this  can  just  as  well  arise  in  an 
operative  cicatrix  as  in  the  cicatricial  tissue  resulting 
from  a  healed  ulcer.  This  argument  in  favour  of 
excision  consequently  loses  the  importance  that  it 
might  appear  to  possess. 

Then,  too,  the  cicatricial  tissue  of  the  ulcer  is  all 
the  more  susceptible  to  malignant  change  because 
constantly  irritated.  If  this  irritation,  for  some 
reason,  ceases,  the  chance  of  the  development  of 
cancer  will  be  reduced.  The  number  of  ulcers 
operated  on  by  so-called  palliative  methods  is  quite 
considerable  at  present,  so  that  conclusive  data  de- 
rived from  clinical  experience  are  to  hand.  We  have 
found  only  one  case  (Mayo-Robson's)  of  secondary 
malignant  transformation  occurring  some  time  after 


182  SURGICAL  TREATMENT 

gastroenterostomy.  Therefore  one  is  compelled  to 
admit  that  palliative  procedures  placing  the  stomach 
and  ulcer  at  rest  reduce  to  the  strict  minimum  the 
risk  of  this  complication. 

At  the  time  of  the  operation  it  will  usually  be 
impossible,  or  at  all  events  delicate,  to  make  a  sure 
diagnosis  between  cancer  and  ulcer,  and  in  all 
statistics  will  be  found  a  group  of  neoplasms  whose 
nature  could  not  be  determined  on  the  operating 
table.  A  clinical  study,  no  matter  how  searching, 
will  not  always  establish  an  exact  diagnosis,  and  there 
are  instances  in  which,  regardless  of  scrupulous 
observation  of  the  evolution  of  the  process,  in  spite 
of  precise  laboratory  search,  even  of  microscopical 
examination  not  infrequently,  the  real  character  of 
the  lesion  will  escape  us. 

As  an  example  of  the  difficulty  encountered  in 
clinical  diagnosis  we  would  mention  the  case  of  a 
young  girl  who  was  admitted  to  hospital  for  serious 
haematemeses  with  characteristic  signs  of  chronic 
ulcer  which  had  been  present  for  some  time.  The 
patient's  general  health  was  precarious,  she  having 
reached  the  ultimate  degree  of  anaemia ;  and  as  the 
hsematemeses  were  controlled  by  completely  resting 
the  stomach,  it  was  decided  to  delay  operation  until 
the  patient  should  have  regained  some  strength. 
After  a  few  days'  observation  the  patient  was  trans- 
ferred to  the  medical  service,  where  such  improve- 
ment took  place  in  such  a  short  time  that  she  was 
discharged  without  being  referred  to  the  surgical 
service. 

Nine  months  later,  after  a  winter  during  which  all 


TYPICAL  GASTRIC   ULCER  183 

the  symptoms  of  chronic  ulcer  returned,  haemate- 
meses  again  occurred,  and  the  family  physician  sent 
the  patient  to  hospital  for  urgent  operation. 

At  this  time  there  was  profound  anaemia ;  the 
haematemeses  could  be  controlled,  so  that  it  was 
decided  to  wait  until  some  slight  improvement  could 
be  obtained  before  operating. 

On  the  third  day  after  entrance  a  rather  con- 
siderable haematemesis  occurred,  and  it  was  then 
determined  not  to  await  another.  The  patient  was 
operated  on  the  following  day,  when  a  chronic  ulcer 
on  the  lesser  curvature  was  found  a  few  centimetres 
from  the  pylorus.  Professor  Girard,  who  operated, 
performed  annular  resection  of  the  stomach,  a  proce- 
dure that  he  was  not  accustomed  to  follow,  as 
circumstances  seemed  to  be  at  first  sight  very 
favourable  for  this  operation.  Convalescence  was 
normal,  but  little  by  little  signs  of  pyloric  stenosis 
became  manifest,  due  probably  to  contraction  of  the 
cicatrix,  extending  almost  to  the  pylorus.  Girard 
almost  regretted  having  done  annular  resection,  and 
not  gastroenterostomy,  when  the  result  of  the 
pathological  examination  caused  him  to  forget  his 
regrets,  as  Professor  Askanazy  reported  that  he  had, 
in  fact,  found  malignant  transformation  of  the  ulcer. 
Nothing  in  this  case — and  especially  the  young  age 
of  the  patient — could  have  led  to  the  suspicion  of 
malignant  change.  The  anatomical  condition  found 
at  operation  and  the  clinical  evolution  of  the  process 
were  those  of  ordinary  chronic  ulcer. 

This  impossibility  of  making  a  clinical  distinction 
is  the  only  real  argument  in  favour  of  resection  of  an 


184  SURGICAL  TREATMENT 

ulcer.  When  placed  at  rest  by  a  palliative  procedure, 
the  lesion  will  not  be  likely  to  undergo  malignant 
change,  but  at  the  time  of  operation  the  ulcer  may 
already  contain  some  neoplastic  cells  without  any 
clinical  evidence  being  present.  It  is,  therefore, 
prudent  in  all  cases  where  suspicious  induration 
exists,  and  this  no  matter  what  may  be  the  patient's 
age,  to  consider  the  ulcer  as  a  malignant  process, 
hence  excise  it.  In  this  way  many  simple  chronic 
ulcers  will  be  excised  for  which  a  palliative  operation 
would  probably  have  been  quite  sufficient,  but  then 
one  will  have  had  the  opportunity  of  removing  in 
some  instances  a  cancer  at  its  onset  which  in  no  way 
gave  rise  to  suspicion  of  malignancy. 

The  consequences  of  such  a  rule  are  too  important 
to  require  further  comment  on  our  part,  all  the  more 
so  because  malignant  transformation  of  gastric  ulcer 
— at  least  at  its  onset — has  little  tendency  to  recur 
or  develop  metastases.  The  results  of  radical  treat- 
ment are  sufficiently  encouraging  for  us  to  unhesi- 
tatingly recommend  them. 

Disadvantages  of  Resection. — As  far  as  the  proce- 
dure is  concerned,  resection  of  the  ulcer  has  many 
convinced  opponents,  who  base  their  opinion  on  the 
inconveniences  or  even  the  danger  of  this  operation. 

The  first  of  these  inconveniences  is  that  resection, 
an  easy  and  benign  interference  in  certain  cases, 
nevertheless  remains  a  serious  operation,  which,  if 
not  exacting  particular  dexterity  on  the  part  of  the 
surgeon,  will  always  require  considerable  time  to 
carry  out.  Local  anaesthesia,  which  may  suffice  in  a 
palliative  operation,  is  not  enough  in  a  radical  pro- 


TYPICAL  GASTRIC  ULCER  185 

cedure.  Therefore  general  narcosis  will  be  required. 
Then,  too,  division  and  traction  made  on  the  gastric 
ligaments  is  not  devoid  of  influence  in  the  production 
of  shock,  which  supervenes  after  these  operations. 
These  circumstances  make  resection  a  serious  inter- 
ference, as  is  proved  by  the  percentage  of  operative 
mortality  at  the  hands  of  various  surgeons.  Out  of  a 
total  of  133  cases  reported  up  to  1911  we  find  that 
the  average  mortality  is  20  per  cent. 

It,  therefore,  results  that  in  most  cases  resections 
should  not  be  undertaken  except  by  surgeons 
familiar  with  gastro-intestinal  surgery.  The  more 
recent  brilliant  results  published  by  men  eminent  in 
this  branch  of  surgery  should  not  encourage  novices 
or  occasional  operators  to  resort  to  these  procedures. 
They  will  certainly  court  disaster.  An  interference 
likely  to  give  a  high  mortality  will  be  proper  in 
desperate  cases  like  cancer,  but  it  hardly  seems  to  be 
indicated  when  the  morbid  process  is  compatible 
with  a  long  survival,  especially  when  less  dangerous 
methods  can  be  resorted  to  with  real  chance  of  success. 

The  second  disadvantage  of  resection  is  to  us 
more  important,  although,  perhaps,  less  evident. 
But  this  disadvantage  concerns  only  a  class  of 
resections  rarely  resorted  to.  We  have  insisted 
lengthily  on  the  nature  and  pathogenesis  of  ulcer ; 
we  have  shown  that  operative  treatment  acts  by 
changing  the  gastric  physiology  :  at  least,  such  is  the 
explanation  which  appears  to  us  to  be  the  most 
logical  for  the  time  being.  This  second  disadvantage 
of  resection  precisely  resides  in  the  fact  that  this 
operation  produces  only  an  insignificant  change  in 


186  SUEGICAL  TEEATMENT 

this  physiology,  or  even  none  whatsoever.  It  deals 
with  the  ulcer,  but  it  leaves  the  rest  of  the  gastric 
mucosa  intact ;  it  has  no  action  upon  it  other  than  to 
cause  the  spasm  to  disappear  or  to  diminish  in  a 
very  uncertain  way  the  reflex  hypersecretion.  The 
gastric  physiology  being  only  slightly  or  not  at  all 
changed,  it  is  to  be  feared  that  recurrences  will  not 
be  long  in  becoming  declared.  And,  better  still,  cases 
of  multiple  ulcer  are  not  so  uncommon  that  they 
should  be  disregarded  or  ignored  in  practice.  Perhaps 
one  may  be  excised,  while  another,  which  has  been 
overlooked — and  this  is  not  exceptional — will  con- 
tinue its  evolution  after  the  interference.  It,  there- 
fore, is  placed  in  the  same  conditions,  or  practically 
the  same,  which  are  so  propitious  for  its  development. 
It  is  for  this  reason  that  recurrences  and  complications 
of  these  overlooked  ulcers,  although  not  frequent, 
nevertheless  are  encountered  from  time  to  time. 

Hence  this  procedure,  although  it  offers  one  serious 
advantage — the  removal  of  cancer  at  the  onset — 
presents  dangers  and  disadvantages  which  render  the 
problem  complex.  In  principle  one  cannot,  therefore, 
give  one's  preference  to  resection,  and  the  different 
types  of  resection  applicable  to  the  various  anato- 
mical types  of  ulcer  are  too  different  for  one  to  be 
able  to  judge  the  entire  question. 

Without  entering  into  the  details  of  operative 
technique,  we  may  say  that  resections  can  be  reduced 
to  three  general  types,  presenting  distinct  characters : 

Atypical  partial  resection. 

Mediogastric  annular  resection. 

Kesection  of  the  pylorus. 


TYPICAL  GASTRIC  ULCER  187 

Atypical  partial  resection  can  be  accomplished  with 
the  knife — the  usual  method — or  with  the  thermo- 
cautery  (Balfour).  The  first  procedure  will  some- 
times lead  to  extensive  resection,  hence  to  deformity 
of  the  stomach.  In  ulcers  of  the  lesser  curvature, 
which  are  the  most  frequent  lesions  of  the  body  of  the 
stomach,  such  a  deformity  would  greatly  interfere 
with  the  gastric  functions.  When  the  ulcer  has 
already  involved  the  pancreas  the  difficulty  in  freeing 
the  adhesions  will  be  considerable  and  haemorrhage 
free.  A  wound  will  be  made  in  the  pancreas  formed 
by  the  fundus  of  the  ulcer  that  will  be  difficult  to 
properly  deal  with.  All  things  considered,  it  is  an 
unsatisfactory  procedure,  while  the  ultimate  results 
are  far  from  encouraging. 

As  to  thermocauterisation  of  the  ulcer,  it  is 
simpler,  less  haemorrhagic  and  less  mutilating,  and 
possesses  an  energetic  action  on  the  penetrating 
fundus  of  the  ulcer.  It  is,  therefore,  infinitely  more 
pleasing.  Up  to  the  present  time  it  has  given  good 
results,  and  those  who  have  employed  it  are  loud  in 
their  praise  of  the  procedure.  But  in  order  to  pass 
final  judgment  it  seems  to  us  more  prudent  to  wait 
until  a  longer  time  has  elapsed  to  ascertain  the 
remote  results,  as  the  procedure  is  a  relatively  recent 
one. 

There  was  a  time  when  annular  resection  was 
regarded  as  the  best  treatment  of  ulcer  of  the  lesser 
curvature.  The  immediate  results  were  encouraging, 
but  at  present  few  operators  resort  to  it,  because  the 
remote  results  have  greatly  deceived  the  early 
partisans  of  this  technique. 


188  SURGICAL  TREATMENT 

The  two  operations  are  analogous  from  the  fact 
that  they  leave  the  sphincter  of  the  pylorus  intact, 
which  is  always  ready  to  contract,  therefore  giving 
rise  to  retention  from  spasm.  When  a  sphincter  has 
been  excited  for  so  long  a  time  and  is  always  ready 
to  shut  down  it  remains  hypersensitive,  and  the  least 
cause  will  produce  spasm.  Therefore  the  stomach 
is  placed  in  the  same  condition  as  before  the  opera- 
tion. If  the  ulcer  were  merely  a  simple  atonic  lesion, 
representing  a  distinctly  characterised  change  of  the 
mucosa,  these  two  operations  would  offer  a  judicious 
means  of  controlling  the  situation  ;  but  in  reality  the 
ulcer  is  only  an  episode,  so  to  speak,  of  a  morbid 
process  which  involves  the  entire  stomach. 

The  pyloric  sphincter  plays  a  very  important  part 
in  the  process  by  regulating  gastric  evacuation  ;  it  is 
frequently  changed  in  its  functions  by  the  affection  in 
which  it  participates,  and  every  effort  should  be  made 
to  preserve  its  principal  function,  that  of  controlling 
and  regulating  evacuation  of  the  stomach.  It  is  for 
this  reason  that  we  believe  that  operations  which  ex- 
tirpate the  ulcer  without  changing  either  the  chemism 
or  pyloric  transit  are  merely  partial  procedures,  com- 
bating certain  immediate  and  alarming  symptoms, 
but  without  exercising  any  action  over  the  general 
morbid  process. 

When  the  ulcer  is  seated  in  the  pylorus  or  its 
immediate  neighbourhood,  resection  assumes  an 
entirely  different  character.  Not  only  is  the  ulcer 
excised,  the  immediate  complications  are  no  longer 
to  be  feared,  but,  what  is  more,  the  sphincter  is 
removed  at  the  same  time  as  the  ulcer ;  gastric  motility 


TYPICAL  GASTRIC  ULCER  189 

will  consequently  be  transformed,  and  this  no  matter 
what  means  of  gastro-intestinal  union  is  adopted. 

These  means  of  union  are  numerous,  as  we  showed 
in  the  chapter  on  pylorectomy.  From  the  view-point 
of  interest  to  us  these  various  procedures  can  be 
grouped  under  two  headings.  In  the  first  the 
anastomosis  is  made  directly  between  the  stomach 
and  duodenum,  as  in  Billroth's  pylorectomy  I.  or  in 
Kocher's  operation.  In  the  second  the  anastomosis 
is  indirectly  accomplished  by  the  jejunum,  as  in 
Billroth's  pylorectomy  II.,  by  means  of  gastroenter- 
ostomy. 

The  advantages  of  the  procedures  of  the  first  type, 
all  questions  of  technique  being  excluded,  are  to 
assure  : — 

(1)  A  good  evacuation  of  the  stomach,  the  sphincter 
offering  no  obstacle. 

(2)  The  utilisation  of  the  duodenum. 

The  importance  of  utilising  the  duodenum  has  only 
been  placed  in  evidence  relatively  recently.  The 
study  of  the  physiology  of  this  segment  of  the 
intestine,  particularly  its  part  in  gastric  interferences, 
is  still  at  its  commencement.  According  to  the  work 
of  Brechot,  D'Albert  and  Frouin,  it  will  be  found 
that  the  duodenum  is  a  centre  of  secretions  and 
reflexes  having  a  capital  importance  in  digestion  in 
general. 

Brechot,  after  having  recognised  that  the  duode- 
num is  the  real  regulator  of  pyloric  transit,  has  more 
particularly  studied  the  physiological  action  of  the 
duodenal  secretions.  According  to  his  experiments, 
likewise  confirmed  by  those  carried  out  by  Frouin, 


190  SURGICAL  TREATMENT 

the  passage  of  food  over  the  duodenal  mucosa  pro- 
vokes the  secretion  of  prosecretine  and  enterokinase. 

When  in  contact  with  the  acid  chyme  coming  from 
the  stomach,  prosecretine  is  transformed  into  secre- 
tine,  which,  absorbed,  acts  by  way  of  the  blood  by 
activating  the  pancreatic  secretion. 

Enterokinase  is  a  ferment  which  acts  as  a  true 
mordant,  to  use  Brechot's  expression,  for  trypsin 
and  lipase.  One  conclusion  of  these  studies,  which  we 
have  only  been  able  to  meagrely  outline,  is  that  the 
passage  of  food  through  the  duodenum  is  necessary 
to  assure  normal  secretion  of  the  pancreas  as  well  as 
complete  utilisation  of  its  active  principles. 

Brechot  found  a  very  considerable  decrease  in  the 
absorption  of  fats — 45  per  cent,  absorbed — following 
gastroenterostomy  which  excludes  the  duodenum  ; 
and  it  was  for  this  reason  that  he  was  tempted  to 
undertake  this  interesting  study. 

Are  we  to  accept  the  conclusion  arrived  at  by 
these  observers  that  any  procedure  which  excludes 
the  duodenum  is  very  prone  to  cause  poor  general 
nutrition  ?  We  do  not  think  so,  and  this  for  three 
reasons  : — 

(1)  Because  one  cannot  assimilate  experiments  on 
healthy    animals    with    operations    undertaken    on 
patients  whose  gastro-intestinal  physiology  is  pro- 
foundly disturbed. 

(2)  Because  in  the  majority  of  the  procedures 
which  utilise  the  duodenum,  gastroenterostomy  in 
particular,  a  more  or  less  accentuated  degree  of  reflux 
is  always  noted,  and  this  reflux,  in  a  certain  measure, 
may  serve  as  an  excitant  for  the  duodenal  secretions. 


TYPICAL  GASTRIC  ULCER  191 

(3)  Because  psychic  excitations  suffice  to  cause  the 
pancreas  and  liver  to  secrete,  just  as  they  cause  secre- 
tion of  the  glands  of  the  gastric  mucosa. 

Nobody  can  deny  that  the  pancreatic  and  duo- 
denal secretions  are  less  considerable  in  amount  and 
less  active,  but  we  refuse  to  believe  that  this  diminu- 
tion is  sufficiently  important  to  bring  about  serious 
disturbances. 

For  those  who,  therefore,  consider  that  surgical 
treatment  only  acts  by  a  mechanical  effect,  by  dis- 
appearance of  the  stasis,  Billroth's  pylorectomy  I. 
presents  all  the  necessary  qualities.  We  have  seen 
that  this  is  a  fashion  of  envisaging  only  one  of  the 
aspects  of  the  question,  and  not  the  most  important 
at  that. 

It  is  entirely  different  in  the  case  of  the  second 
procedure  of  pylorectomy,  otherwise  Billroth's  II. 
This  operation  is  essentially  different ;  it  is  complex, 
and  from  this  fact  it  approaches  combined  operations, 
resection  and  gastroenterostomy.  We  will  conse- 
quently consider  it  when  we  refer  to  this  special  type 
of  procedure.  Let  it  at  once  be  said  that  of  all  the 
pylorectomies  this  one  is  the  most  employed  for 
technical  reasons,  as  has  already  been  said,  and 
because  it  combines  the  therapeutical  advantages 
of  resection  and  gastroenterostomy. 

More  and  more  the  indications  of  pylorectomy  are 
being  broadened,  and  the  extent  of  the  excision  is 
becoming  decidedly  free,  so  that  the  term  "  pyloro- 
gastrectomy  "  is  at  present  being  used.  The  indica- 
tions for  this  procedure  include  ulcer  of  the  lesser 
curvature  even  when  seated  high  up  in  proximity 


192  SURGICAL  TREATMENT 

to  the  cardia.  Extensively  employed  at  first  in 
Austria  and  Germany,  this  procedure  is  unquestion- 
ably the  one  that  gives  the  best  results.  Moynihan 
believes  that  patients  recover  from  it  more  rapidly 
than  from  any  other  procedure,  and  that  recurrences 
of  the  lesion  are  rare. 

Not  only  is  the  ulcer  excised,  the  pyloric  spasm 
abolished,  but,  what  is  more,  the  surface  secreting 
HC1  is  considerably  reduced,  so  that  the  alkaline 
secretions  can  flow  back  on  to  what  remains  of  the 
gastric  cavity.  Therefore  all  the  guarantees  of 
permanent  cure  are  here  united. 

Gastroenterostomy  :  its  Advantages. — Gastroente- 
rostomy  is  certainly  the  operation  most  frequently 
employed  in  cases  of  ulcer  in  activity.  Some  con- 
sider it  a  makeshift ;  others,  especially  Mayo-Robson, 
Moynihan,  Hartmann  and  Monprofit,  have  been  able 
to  form  an  opinion  of  this  operation  based  on  a  very 
long  experience,  and  prefer  it  to  other  procedures. 
Finally,  others  accept  a  moderate  average  and  boldly 
declare  that  gastroenterostomy  does  not  deserve 
either  bitter  criticism  or  excessive  praise. 

The  principal  advantages  offered  by  gastroenteros- 
tomy are : — 

(1)  A  simple  and  rapid  technique. 

(2)  A  minimum  of  danger. 

(3)  To  assure  a  good  evacuation  of  the  stomach. 

(4)  To  produce  as  complete  a  transformation  of 
the  gastric  chemism  as  is  possible. 

In  fact,  gastroenterostomy  is  an  operation  whose 
technique  is  now  regulated  and  familiar  to  all 
operators.  Performed  in  good  circumstances  by  a 


TYPICAL  GASTRIC   ULCER  19S 

surgeon  of  some  dexterity,  it  should  never  take  more 
than  fifteen  to  twenty-five  minutes  to  carry  out. 
In  the  cases  where  the  patient's  general  health 
requires  this  operation  the  time  taken  in  performing 
it  may  be  reduced  to  a  few  minutes  if  Murphy's 
button  is  employed.  Gastroenterostomy  produces 
little  operative  trauma,  the  gastric  ligaments  are 
not  pulled  upon,  nor  are  the  sympathetic  nerve  fila- 
ments divided  as  in  resection.  Prom  this  fact  this 
procedure  can  be  done  without  general  narcosis, 
nerve  blocking  being  enough,  if  ether  or  chloroform 
be  contra-indicated. 

So  many  precautions,  it  has  been  said,  are  not 
often  necessary  in  simple  ulcer  when  complications 
have  not  aggravated  the  patient's  general  condition. 
They  are  unfortunately  very  often  useful  given  the 
condition  of  real  cachexia  into  which  patients  with 
simple  ulcer  have  fallen  before  they  decide  to  consult 
a  surgeon. 

Gastroenterostomy  assures  good  evacuation  of  the 
stomach.  Whether  the  ulcer  is  seated  in  the  pylorus 
or,  on  the  contrary,  seated  more  or  less  remotely  from 
it,  the  operation  invariably  creates  an  outlet,  and  this 
outlet  is  never  influenced  by  spasm. 

For  some  adversaries  of  gastroenterostomy  gastric 
evacuation  is  not  regular  :  the  stoma  merely  acts 
like  a  safety-valve  carrying  off  the  overflow  of  the 
gastric  contents.  It  is  unquestionable  that  in  some 
cases,  representing  a  small  majority,  the  gastric 
transit  remains  slow  after  the  operation.  These 
cases  are  generally  the  chronic  ones,  in  which  the 
long  duration  of  the  process  has  already  reacted  on 


S.T 


194  SUKGICAL  TREATMENT 

the  walls  of  the  stomach,  removing  their  contracti- 
lity. For  that  matter,  such  cases  are  rare,  as  is 
proved  by  examination  of  the  gastric  functions  after 
operation. 

Is  the  gastric  evacuation  continuous,  and  does  it 
definitely  take  place  through  the  stoma  ?  Such 
was  supposed  to  be  the  case  until  recently,  regardless 
of  Killing's  work,  but  radioscopical  examination  of 
the  gastric  motility  after  operation  has  undeceived 
surgeons  in  this  respect.  It  is  now  known  that  the 
stoma  only  carries  out  its  functions  when  a  stenosis 
of  the  pylorus  prevents  normal  evacuation  of  the 
stomach.  We  have  referred  to  the  importance  of 
post-operative  radiographical  study  of  these  cases 
when  speaking  of  pyloric  stenosis,  and  this  importance 
is  infinitely  greater  in  the  treatment  of  ulcer  in 
activity. 

In  point  of  fact,  even  if  the  ulcer  creates  an 
obstacle  to  the  transit  through  the  pylorus,  it  can 
only  effect  this  by  either  tumefaction  or  spasm,  and 
not  by  cicatricial  contraction,  more  or  less  definitely 
permanent.  These  two  causes  of  stenosis  are 
directly  dependent  upon  the  evolution  of  the  ulcer ; 
that  is  to  say,  they  are  susceptible  to  diminish  or  to 
even  completely  disappear  when  a  cure  of  the  causal 
affection  has  been  wrought. 

Prom  this  time  on  what  becomes  of  the  functions 
of  the  stoma  ?  The  pylorus  being  again  patent, 
the  gastric  contents  will  be  essentially  carried  off  by 
the  natural  route,  and  will  little  by  little  give  up 
the  roundabout  road  created  by  the  stoma.  The 
latter  being  abandoned,  will  have  a  tendency  to 


TYPICAL  GASTRIC  ULCER  195 

contract,  and  will  finally  be  completely  occluded. 
The  stomach  will  then  be  in  the  same  condition  as 
before  the  interference. 

As  might  be  supposed,  before  the  stoma  ceases  to 
functionate  the  ulcer  will  have  had  both  time  and 
opportunity  to  undergo  cicatrisation,  because  it  is  its 
cure  that  has  permitted  the  gastric  contents  to 
follow  their  normal  course.  It  is  even  certain  that 
it  cannot  be  otherwise,  but  is  cicatrisation  advanced 
and  solid  enough  to  resist  new  irritations  resulting 
from  the  passage  of  food  ?  Has  the  gastric  mucosa 
been  sufficiently  altered  by  the  consequences  of 
gastroenterostomy,  consequences  which  play  a 
capital  part  in  the  definite  cure  of  the  ulcer  ? 

In  the  great  majority  of  patients  it  may  be  admitted 
that  such  is  the  case,  given  the  numerous  permanent 
cures  that  have  been  recorded  after  gastroenteros- 
tomy ;  but  among  the  untoward  results  reported 
recurrences  occurring  at  a  more  or  less  remote  date 
after  the  operation  remain,  for  the  most  part, 
unexplained,  the  cause  of  the  failures  having  been 
impossible  to  demonstrate.  We  believe  that  it  need 
only  be  looked  for  in  the  occlusion  of  the  stoma 
resulting  from  patency  of  the  pylorus. 

In  fact,  what  takes  place  when  gastroenterostomy 
is  done  for  a  prepyloric  ulcer  producing  pyloric 
stenosis  ?  Directly  after  the  operation  the  stoma  is 
large,  and  the  gastric  contents,  finding  an  obstacle  to 
their  normal  transit,  empty  into  the  new  opening ; 
the  stasis  disappears,  and,  what  is  more,  the  pancreatic 
duodenal  reflux  exerts  its  therapeutical  influence. 

The  ulcer  having  been  placed  at  rest,  as  well  as  the 

o  2 


196  SURGICAL  TREATMENT 

remainder  of  the  gastric  mucosa,  the  tumefaction 
surrounding  the  lesion  subsides,  the  spasm  provoked 
by  it  occurs  less  and  less  frequently,  and  the  pylorus 
progressively  allows  some  food  to  pass  through. 

As  the  pylorus  becomes  more  patent  and  more 
continuously  permeable  the  gastric  contents  aban- 
don the  stoma,  which  at  length  is  occluded  from 
disuse.  As  we  have  said,  the  stomach  will  then 
be  in  the  same  condition  as  before  the  interference. 
The  reflux  of  bile  and  pancreatic  juice  no  longer  takes 
place,  and  the  mucosa  again  secretes  a  hyperactive 
gastric  juice  if  the  influence  of  the  operation  has  not 
been  allowed  to  be  felt  for  a  sufficient  length  of  time. 
These  acid  secretions  are  not  devoid  of  action  on  a 
fresh  cicatrix  of  an  ulcer  still  surrounded  by  an  area 
of  tissues  whose  nutrition  is  disturbed  by  vascular 
thromboses  that  are  always  to  be  found  at  a  certain 
distance  from  the  lesion. 

In  the  same  way  the  still  sensitive  cicatrix  is  con- 
tinually irritated  by  the  passage  of  food ;  hence  the 
spasm  recurs.  The  gastric  contents  have,  therefore, 
difficulty  in  flowing  off  by  the  pylorus  ;  stasis  is 
produced  that  the  occluded  stoma  can  no  longer 
overcome,  or,  at  least,  it  can  only  deal  with  it 
imperfectly. 

The  ulcer  consequently  is  faced  with  all  the  circum- 
stances favourable  for  its  development,  just  as  it  was 
before  operation.  These  are  hyperchlorhydria, 
circulatory  disturbances  and  stasis. 

This  explanation  of  recurrence  of  the  ulcer  may, 
perhaps,  appear  to  be  hypothetical.  However,  it  is 
based  upon  the  now  well-known  fact  that  the  stoma 


TYPICAL  GASTRIC  ULCER  197 

no  longer  serves  any  purpose  when  the  pylorus  is 
patent,  and  in  an  ulcer  in  activity  this  permeability 
returns  along  with  the  cure  of  the  ulcer.  This 
explanation  is  further  confirmed  by  Neuhaus'  remark 
in  which  he  recognises  that  the  bile  and  pancreatic 
juice  are  always  encountered  in  stomachs  after 
gastroenterostomy  when  the  pylorus  was  definitely 
stenosed  at  the  time  of  operation,  while  they  disap- 
pear after  a  time  in  subjects  whose  pylorus  was  not 
stenosed,  or  only  momentarily  so,  as  is  the  case  in 
simple  ulcer. 

The  conclusion  that  should  be  derived  from  this 
exposti  is  that  gastroenterostomy  is  a  fallacious  opera- 
tion which  merely  gives  an  appearance  of  cure  or  only 
a  momentary  recovery.  Neuhaus'  findings,  in  fact, 
prove  that  the  principal  advantage  of  gastroenteros- 
tomy— the  continual  reflux  of  the  duodenal  secre- 
tions— is  merely  temporary.  However,  these  re- 
searches, although  they  reveal  the  defect  of  simple 
gastroenterostomy,  at  the  same  time  furnish  a  means 
of  remedying  it. 

Since  the  gastroenterostomies  performed  on 
stomachs  with  pyloric  stenosis  continue  to  func- 
tionate, assuring  at  the  same  time  the  regular 
evacuation  of  the  stomach  and  an  automatic  alkali- 
nisation  of  the  gastric  secretions,  why  not  produce  a 
permanent  stenosis  of  the  pylorus  in  cases  of 
gastroenterostomy  ?  By  this  means  the  permanence 
of  the  functions  of  the  stoma  and  their  consequences 
will  be  assured. 

Exclusion  of  the  pylorus  combined  with  gastro- 
enterostomy was  employed  by  von  Eiselsberg, 


198  SURGICAL  TREATMENT 

Jonnesco  and  Berg,  only  to  mention  those  who  have 
been  rather  loud  in  their  recommendation  of  this 
procedure  in  cases  of  haemorrhagic  pyloric  ulcer. 
The  motive  dictating  this  procedure  was  the  advan- 
tage that  they  recognised  in  placing  the  ulcer  out  of 
the  way  of  the  irritating  contact  of  the  gastric  con- 
tents. But  pyloric  exclusion  is  not  to  be  confined  to 
the  single  indication  of  haemorrhage  ;  it  should,  on 
the  contrary,  as  Professor  Girard  showed,  be  extended 
to  all  cases  in  which  a  permanent  transformation  of 
the  gastric  physiology  is  desired.  We  have  in  it  a 
simple  means,  based  on  theoretical  studies  them- 
selves confirmed  by  clinical  practice  and  experience, 
of  perfecting  an  operation  which  we  do  not  hesitate 
to  qualify  as  excellent,  like  gastroenterostomy. 

It  is  likewise  important  to  choose  as  between  the 
various  procedures  of  gastroenterostomy  that  one 
which  gives  both  regular  evacuation  of  the  stomach 
and  the  best  neutralisation  of  the  gastric  juice. 

When  speaking  of  the  operative  technique  of 
gastroenterostomy,  we  pointed  out  that  the  two 
procedures  at  present  admitted  to  be  the  best  from 
the  view-point  of  gastric  evacuation  are  Roux's 
Y  technique  and  that  of  von  Hacker.  These  pro- 
cedures are,  so  to  speak,  the  only  ones  employed  at 
present,  the  former  especially  in  France,  the  second 
in  England,  the  United  States  and  Germany.  These 
procedures,  which  offer  equivalent  advantages,  as  to 
the  regularity  of  their  functions,  are  very  different  in 
regard  to  their  special  therapeutical  action  on  an 
ulcer  in  activity. 

Von  Hacker's  posterior  anastomosis  permits  the 


TYPICAL  GASTRIC   ULCER  199 

duodenal  reflux  to  take  place ;  Roux's  Y  procedure 
opposes  it.  The  difference  between  the  two  is,  there- 
fore, capital.  By  this  procedure  the  most  important 
action  of  surgical  treatment  is  lost.  And,  what  is  more, 
in  Roux's  technique  the  development  of  a  peptic 
ulcer  on  the  vertical  branch  of  the  Y  is  far  more  prone 
to  occur,  due  to  the  action  of  the  acid  juice  coming 
directly  from  the  stomach  without  having  been  pre- 
viously neutralised. 

It  is  consequently  prejudicial  when  certain  surgeons, 
and  not  the  least,  proclaim  that  Roux's  gastro- 
enterostomy  is  an  ideal  operation  and  recommend  it 
particularly  in  cases  of  non-malignant  lesions  of  the 
stomach.  In  their  opinion,  von  Hacker's  procedure 
being  only  good  in  desperate  cases,  a  defective 
evacuation  or  a  vicious  circle  will  not  be  of  any 
import. 

In  reality  at  present  it  is  recognised  that  in 
cancerous  stenosis  there  is  the  choice  between  the 
two  procedures  according  to  the  preference  of  the 
surgeon,  but  in  benign  affections  and  in  disturbances 
of  the  secretion,  as  Reichmann's  disease  and  ulcer 
particularly,  the  Y  procedure  should  be  discarded, 
and  only  that  of  von  Hacker  employed. 

Roux  himself  does  not  employ  his  procedure  in 
cases  of  hyperacidity,  and  prefers  to  do  posterior 
transmesocolic  anastomosis  for  the  motives  we  have 
exposed.  Von  Hacker's  anastomosis  should  even  be 
resorted  to  in  a  somewhat  particular  fashion.  It  is, 
in  fact,  recommendable  to  assure  as  large  a  stoma 
as  possible  between  the  jejunum  and  the  stomach. 
For  this  there  should  be  no  hesitancy  in  creating 


200  SURGICAL  TREATMENT 

a  stoma  from  8  to  10  centimetres  long,  and  this 
has  been  our  practice  for  many  years.  Such  a 
large  gastro-intestinal  communication  assures  better 
drainage  of  the  alkaline  intestinal  secretions  and 
hyperacid  gastric  juice.  Hence  not  only  the  stoma 
should  allow  the  reflux  of  the  duodenal  secretions 
into  the  stomach,  and  therefore  the  Y  procedure 
be  rejected,  but,  still  more,  one  should  attempt  to 
facilitate  the  free  flow  by  as  large  a  stoma  as  possible. 

Disadvantages  of  Gastroenterostomy. — Regardless 
of  the  advantages  enumerated,  some  surgeons  still 
maintain  that  gastroenterostomy  is  not  a  favourable 
procedure  for  gastric  ulcer.  They  regard  as  hypo- 
thetical and  unfounded  the  action  of  the  pancreatico- 
biliary  reflux  on  the  evolution  of  the  ulcer.  On  the 
other  hand,  they  believe  gastroenterostomy,  which 
does  not  directly  deal  with  the  ulcer,  cannot  prevent 
serious  complications  from  ensuing,  such  as  haemor- 
rhage and  perforation. 

Others  maintain  that  by  short-circuiting  the  flow 
of  food  gastroenterostomy  transforms  the  general 
nutrition  too  much  to  be  a  good  operation. 

Such  are  the  chief  disadvantages  that  are  laid  at 
the  door  of  this  procedure.  We  have  too  lengthily 
insisted  on  the  unquestionable  therapeutical  action 
of  alkalinisation  of  the  gastric  juice  on  the  ulcer  to 
again  refer  to  it.  If  these  few  writers  will  not  admit 
its  importance,  it  must  be  said  that  they  do  not 
found  their  opinion  on  any  theoretical  or  practical 
data. 

When  we  considered  the  advantages  of  resection 
we  referred  to  the  danger  inherent  to  the  ulcer  left 


TYPICAL  GASTRIC  ULCER     201 

intact,  ready  to  give  rise  to  serious  complications. 
We  pointed  out  that  this  fear,  which  appears  logical 
at  first  sight,  is  more  theoretical  than  otherwise.  The 
ulcer  placed  at  rest  by  gastroenterostomy  has  little 
chance  of  giving  rise  to  haemorrhage  or  perforation  ; 
cases  are  known  in  which  these  complications  have 
occurred,  but  they  are  few.  In  most  instances  they 
accrued  a  long  time  after  the  operation,  frequently 
after  a  period  of  manifest  amelioration.  In  fact,  such 
cases  are  true  recurrence  of  the  ulcer,  and  not  merely 
a  continuation  of  the  evolution  of  the  lesion. 

These  recurrences  can  be  prevented  in  a  large 
measure  by  exclusion  of  the  pylorus,  and  can  take  place 
in  other  procedures,  namely,  resections.  In  the  case 
of  the  latter  procedures  the  recurrence  of  the  ulcer 
naturally  does  not  take  place  on  the  same  spot  as  the 
first  lesion,  but  the  physiological  or  pathological 
condition  of  the  stomach  favours  the  development 
of  new  ulcers  at  other  parts  of  the  mucosa.  Whether 
the  same  ulcer  recurs  or  other  ulcers  develop,  the 
practical  result  is  the  same. 

As  to  the  serious  complication  of  malignant  trans- 
formation of  the  ulcer,  we  attempted  to  show  that  by 
placing  the  stomach  at  rest,  thus  allowing  rapid 
cicatrisation  of  the  lesion,  this  transformation  is 
infinitely  infrequent.  This  is,  however,  in  our 
opinion,  the  only  serious  argument  that  can  be 
opposed  to  partisans  of  gastroenterostomy.  It  is 
preferable  to  discard  this  operation  when  the  slightest 
doubt  exists  as  to  the  nature  of  the  ulcer,  no  matter 
if  the  symptoms  are  apparently  benign. 

From  the  study  of  the  advantages  either  of  resec- 


202  SURGICAL  TREATMENT 

tion  or  gastroenterostomy  the  conclusion  arrived  at 
is  that  neither  of  these  procedures  is  perfect  and 
gives  absolute  security,  if  not  immediate,  at  least 
remote.  Therefore  these  two  operations  have  been 
combined  in  order  to  obtain  sure  results,  immediate 
by  resection,  remote  by  gastroenterostomy. 

This  combination,  in  fact,  unites  the  advantages 
inherent  to  each  procedure.  Unfortunately  it  offers 
the  great  disadvantage  of  being  long  and  rather 
laborious,  and,  from  this  fact,  cannot  be  carried  out 
on  patients  not  sufficiently  resistant.  It  is  true  that 
in  ulcer  patients  with  general  health  profoundly 
involved  the  procedure  can  be  decomposed,  as  has 
been  proposed  by  Thudske  in  cancer  of  the  pylorus. 
Gastroenterostomy  is  first  done,  which  allows  the 
patient  to  be  fed  up  and  to  acquire  the  necessary 
strength  to  undergo  the  more  important  operation. 

This  procedure  in  one  or  two  steps  is  particularly 
indicated,  and  is  the  most  frequently  employed,  when 
the  ulcer  is  seated  near  the  pylorus.  It  merely  con- 
sists of  Billroth's  pylorectomy  II.  We  have  already 
spoken  of  the  technique  of  these  pyloric  resections, 
and  especially  of  the  means  of  union  between  the 
stomach  and  intestine.  We  pointed  out  the  very 
relative  advantages  that  some  surgeons  recognised 
in  Billroth's  I.  and  Kocher's  technique.  Already 
very  questionable  in  cases  of  cancer,  these  advan- 
tages are  far  from  being  compensated  in  cases  of 
ulcer  by  those  of  indirect  union,  as  in  Billroth  II. 

Gastroenterostomy  added  to  pyloric  resection  is, 
in  fact,  an  excellent  procedure  and  one  which  gives 
perfect  results.  Moynihan  believes  that  it  is  the 


TYPICAL  GASTRIC  ULCER  203 

procedure  which  gives  the  most  complete  and  durable 
recovery  with  the  best  gastric  functional  work. 
From  what  has  been  said  the  reason  for  this  is  simple : 
the  pylorus  is  completely  occluded  ;  all  transit  must 
be  through  the  stoma,  and  this  without  any  fear 
as  to  ulterior  closing  down  of  the  new  opening. 
Resection  of  the  ulcer  has  the  same  effect  as  exclusion 
of  the  pylorus,  an  indispensable  complementary 
operation  for  the  regular  functionating  of  the  stoma. 

When  the  ulcer  is  seated  at  a  point  remote  from  the 
pylorus,  gastroenterostomy  will  no  longer  be  neces- 
sary ;  simple  suture  of  the  edges  of  the  excision 
or  mediogastric  circular  suture  assures  the  continuity 
of  the  digestive  canal.  The  part  played  by  gastro- 
enterostomy therefore  appears  less  evident,  yet  we 
believe  that  it  is  quite  as  real  ;  its  importance 
results  from  the  changes  it  brings  about  in  gastric 
chemism.  Therefore,  whether  the  ulcer  is  seated  in 
the  pylorus  and  a  pylorectomy  is  done,  or  whether 
it  is  seated  at  some  other  part  of  the  stomach,  gastro- 
enterostomy will  invariably  be  useful,  and  should  be 
combined  with  resection.  By  this  means  the  direct 
local  treatment  of  the  ulcer  is  assured,  the  immediate 
accidents  which  might  occur  are  prevented,  while  at 
the  same  time  by  treating  the  causal  affections — 
hyperchlorhydria  and  hypersecretion — recurrences 
and  remote  disturbances  will  be  avoided.  But  to 
carry  this  out  the  patient  must  be  sufficiently 
resistant  to  support  a  serious,  long  and  depressing 
operation.  Too  much  stress  cannot  be  laid  on  this 
point. 

Jejunostomy. — Finally,  in  some  cases,   although 


204  SURGICAL  TREATMENT 

infrequent,  it  is  true,  an  operation  of  a  decidedly 
palliative  kind  has  been  employed  in  ulcer  in  activity. 
We  refer  to  jejunostomy.  The  only  function  of  this 
procedure  is  to  place  the  stomach  as  completely  at  rest 
as  is  possible  for  the  length  of  time  necessary  to  heal 
the  ulcer.  When  the  clinical  signs  of  the  lesion  have 
subsided,  feeding  per  os  may  be  returned  to,  and  the 
jejunal  stoma  will  close  spontaneously  in  a  few  days. 

Maydl  and  von  Eiselsberg  mention  several  cases 
of  complete  cure  of  chronic  ulcer  by  this  means,  thus 
proving  that  the  procedure  is  really  valuable.  It 
especially  offers  two  advantages,  namely,  firstly,  that 
it  places  the  stomach  at  complete  rest,  and,  secondly, 
the  technique  is  quickly  carried  out  through  a  small 
incision  in  the  peritoneum ;  hence  general  narcosis 
becomes  unnecessary.  These  advantages  are  par- 
ticularly evident  in  cases  complicated  by  perforation 
or  haemorrhage,  while  they  are  especially  manifest  in 
chronic  ulcer,  but  less  so  in  other  types  of  the  lesion. 
Nevertheless  in  certain  selected  cases  this  operation 
may  render  a  real  service. 

In  very  advanced  types  of  ulcer  in  which  the  lesion 
has  penetrated  the  hepatic  parenchyma,  therefore 
when  resection  is  impossible,  Moynihan  has  performed 
jejunostomy  combined  with  gastroenterostomy.  This 
procedure  has  given  good  results,  but,  we  repeat,  it 
should  be  reserved  for  distinctly  definite  lesions. 

To  conclude,  we  would  say  that  the  operation  of 
choice  in  simple  ulcer  in  evolution  is  resection  of  the 
ulcer  combined  with  gastroenterostomy.  The  best 
procedure  is  unquestionably  pylorogastrectomy, 
which  can  be  made  sufficiently  extensive  to  include 


TYPICAL  GASTRIC  ULCER  205 

ulcers  of  the  lesser  curvature  seated  near  the  cardia. 
Very  limited  ulcers  can  be  dealt  with  by  Balfour's 
technique,  but  we  believe  that  it  will  be  more  prudent 
to  complete  the  operation  by  gastroenterostomy. 

In  ulcer  near  the  pylorus,  when  the  patient's 
condition  requires  a  rapid  interference,  gastroenteros- 
tomy with  blockage  of  the  pylorus  may  be  done. 
Ulcer  of  the  lesser  curvature  may  be  dealt  with  by 
blocking  a  portion  of  the  stomach,  even  extensively 
in  some  instances. 

Finally,  in  particularly  serious  cases  jejunostomy 
as  a  last  resort  may  render  great  service  alone  or 
combined  with  gastroenterostomy. 


CHAPTEB  VIII 

THE    INDICATIONS   FOR   OPERATION    IN   H^MORRHAGIC 

ULCER 

HEMORRHAGE  is  one  of  the  most  constant  symp- 
toms of  ulcer,  since  it  is  generally  admitted  to  occur 
in  80  per  cent,  of  the  cases.  Usually  it  possesses 
the  value  of  a  symptom,  unquestionably  important, 
but  which  only  too  frequently  is  overlooked,  and 
consequently  does  not  furnish  any  special  indication 
for  treatment  of  the  causal  affection.  But  although 
this  is  true  for  the  majority  of  cases,  in  some  the 
haemorrhage  ceases  to  be  merely  a  symptom  of  ulcer  ; 
it  may  become  a  serious  complication,  so  dangerous, 
in  fact,  that  it  overshadows  all  other  therapeutical 
indications  and  plays  a  capital  part  in  the  discussion 
of  indications  for  operation. 

Although  the  cases  in  which  haemorrhage  may  be 
the  only  cause  for  operative  interference  are  uncom- 
mon, it  has  appeared  to  us  that  this  subject  requires 
special  consideration.  Haemorrhage  due  to  ulcer 
may  assume  very  varied  forms,  Savariaud  having 
well  described  the  principal  types.  Besides  the  so- 
called  latent  or  occult  haemorrhage,  these  types  are  : — 

Superacute  or  fulminating  hcemorrhage. 

Severe  recurring  hcemorrhage. 

Chronic  hcemorrhage,  that  is  to  say,  a  relatively 
slight  loss  of  blood,  but  so  frequently  repeated  that 


ILEMORRHAGIC  ULCER  207 

it  finally  becomes  disquieting  on  account  of  the 
anaemia  to  which  it  gives  rise. 

These  forms  of  haemorrhage  do  not  respond  to  any 
distinct  type  of  ulcer ;  for  example,  superacute 
haematemesis  may  quite  as  well  arise  at  the  onset  of 
an  acute  ulcer  as  during  the  evolution  of  a  chronic 
ulcer.  It  can  likewise  be  due  to  an  ulcer  seated  in  the 
pylorus  as  well  as  to  one  located  in  the  lesser  curva- 
ture, the  ulcers  being  soft  or  indurated.  The  form 
of  the  haemorrhage  cannot  therefore  by  itself  give 
any  data  as  to  the  type  of  ulcer  giving  rise  to  it. 

In  order  to  outline  the  operative  indications  it  is 
nevertheless  of  the  utmost  importance  to  know  what 
type  of  ulcer  is  giving  rise  to  the  loss  of  blood.  Conse- 
quently an  exact  accounting  must  be  made  of  the 
concomitant  symptoms  and  the  gastric  antecedents 
offered  by  the  patient.  It  is  these  secondary  circum- 
stances which,  according  to  their  nature,  will  often 
lead  the  physician  to  suspect  that  a  spontaneous 
cessation  of  a  serious  haematemesis  may  take  place, 
while  in  other  circumstances  they  may  encourage 
or  even  persuade  him  to  advise  operation  in  face  of 
an  apparently  insignificant  loss  of  blood. 

The  study  of  these  circumstances  will  decide  the 
special  indications  presented  in  each  particular  case, 
and  proves  once  again  how  difficult  it  is  in  practice 
to  formulate  the  rules  for  operation  in  cases  of 
gastric  haemorrhage  due  to  ulcer. 

Superacute  or  Fulminating  Haemorrhage 

The  operations  for  superacute  haemorrhage  are  still 
a  matter  of  much  discussion,  and  opinion  differs 


208  SURGICAL  TREATMENT 

greatly.  It  is,  in  fact,  difficult  to  form  a  decided 
opinion  in  respect  to  the  value  of  the  various  proce- 
dures advised,  all  the  more  so  because  the  surgeon 
usually  has  not  even  the  time  in  which  to 
interfere. 

The  real  fulminating  haemorrhage,  due  to  an 
erosion  of  a  good-sized  artery  like  the  splenic  or 
pyloric,  is  not  only  rather  infrequent,  but,  what  is 
more,  those  cases  in  which  the  violence  of  the  haemor- 
rhage would  seem  to  make  operation  advisable  are 
still  more  infrequent.  Finally,  those  instances  in 
which  circumstances  are  rather  favourable  for  opera- 
tive interference  are  exceptional.  Therefore  no  clear 
idea  can  be  formed  from  the  literature  of  the  subject 
or  otherwise. 

It  can  readily  be  conceived  that  in  extreme  cases 
operation  may  be  regarded  as  the  only  chance,  a 
chance  which  is  unquestionably  small  as  well  as 
uncertain.  But  at  the  onset  of  a  superacute  haemor- 
rhage can  one  foresee  how  it  will  end  ?  Is  it  possible 
to  surmise  the  importance  of  the  vessel  that  bleeds  ? 
And  may  it  not  be  hoped  that  the  loss  of  blood  will 
be  less  serious  than  the  frequently  dramatic  onset 
might  lead  one  to  suppose  ? 

We  have  the  data  which  speak  distinctly  in  favour 
of  the  latter  hypothesis.  For  example,  von  Leube, 
with  his  really  extensive  experience  in  the  medical 
treatment  of  gastric  ulcer,  has  come  to  the  conclusion 
that  these  acute  haemorrhages  with  disquieting  onset 
spontaneously  cease  in  the  vast  majority  of  cases. 
He  maintains  that  if  the  stomach  be  kept  completely 
at  rest  and  with  an  icebag  applied  over  the  epigas- 


JLEMORRHAGIC  ULCER  209 

trium  the  patients  will  recover  from  the  complication, 
which  at  first  sight  seemed  doomed  to  a  fatal  issue. 
He  does  not  deny  the  possibility  of  a  fatal  haemor- 
rhage, but  from  his  experience  he  maintains  that  such 
an  outcome  is  extremely  rare  and  is  then  so  sudden 
and  fulminating  that  it  will  be  usually  too  late  to 
operate. 

On  the  contrary,  Dieulafoy  believes  that  no 
hesitation  should  be  possible.  A  patient  with  a 
severe  haematemesis,  especially  if  repeated,  should 
be  operated  on  without  delay. 

We  have  here  two  opinions  diametrically  opposed 
to  each  other  emanating  from  two  physicians  of 
unusually  long  and  large  clinical  experiences. 

Such  categorical  assertions,  although  undoubtedly 
convenient,  are  hardly  more  than  theoretical,  and 
are  thoroughly  inadequate  from  the  view-point  of 
actual  practice.  To  wait  until  a  very  serious 
haemorrhage  has  been  complacent  enough  to  cease 
from  the  exhibition  of  the  haemostatic  measures  of 
internal  medicine  and,  if  death  occurs,  to  be  consoled 
by  the  thought  that  an  operation  would  after  all 
be  impossible  or  fruitless  in  results,  or  to  under- 
take an  operation,  always  a  risky  matter,  as  soon 
as  the  patient  has  vomited  a  couple  of  quarts  of 
blood — such  is  the  dilemma  with  which  one  is 
confronted. 

We  say  that  the  operation  is  risky.  In  point  of 
fact,  it  must  not  be  presumed  that  the  operative 
treatment  of  gastric  haemorrhage  gives  immediately 
brilliant  results  such  as  those  obtained  in  ulcer  in 
general.  The  statistics  of  operations  for  haemorrhage, 


210  SUEGICAL  TREATMENT 

in  fact,  show  that  the  mortality  oscillates  between 
62  per  cent,  and  66  per  cent. 
This  high  death-rate  is  due  to  : — 

(1)  The  state  of  prostration  of  these  patients. 

(2)  The    very    imitility    of    the    operation,    the 
haemorrhage  continuing  as  severely  as  before. 

(3)  The   difficulties   often   encountered   at   these 
interferences. 

It  is  useless  to  insist  on  the  bad  conditions  in  which 
these  interferences  must  be  undertaken.  Occa- 
sionally the  operation  not  only  does  not  save  the 
patient,  but  is,  on  the  contrary,  le  coup  de  grace.  In 
reality  the  operation  may  be  complicated,  long  and 
laborious,  although  there  are  no  special  signs  which 
might  lead  one  to  foresee  the  difficulties  that  surge 
up  before  the  operator. 

Local  or  infiltration  anaesthesia,  sufficient  in  some 
cases,  will  usually  have  to  be  replaced  by  general 
narcosis  in  order  to  allow  the  surgeon  to  operate  in 
the  depths  of  the  abdomen  with  that  rapidity 
required  by  the  suddenness  of  the  occurrence.  It 
is  not  always  easy  to  discover  the  source  of  the  bleed- 
ing. Even  on  the  operating  table  this  search  may 
be  very  long,  and  is  not  always  crowned  by  success. 
And  when  the  bleeding  point  is  found  what  should  be 
done  ?  Some  advise  excision  of  the  ulcer,  others  a 
purse-string  ligature,  etc.  All  these  procedures  may 
be  rendered  very  difficult  when  adhesions  or  clots  are 
in  the  way. 

For  these  reasons  the  great  majority  of  experienced 
surgeons,  among  whom  are  those  who  can  certainly 
be  regarded  as  very  radical  in  opinion,  believe  that 


ILEMORRHAGIC  ULCER  211 

it  is  better  practice  to  abstain  in  cases  of  acute 
haemorrhage.  With  certain  exceptions,  we  are  pre- 
pared to  make  this  a  general  rule.  It  is  based  upon 
the  fact  that  the  dangers  inherent  in  the  interference 
are  too  great  and  much  exceed  the  risks  that  medical 
treatment  offers.  In  point  of  fact,  Soupault  estimates 
that  good  results  are  obtained  in  80  per  cent,  of  the 
cases  treated  medically,  this  treatment  consisting 
principally  of  nothing  but  rest.  Nevertheless,  accord- 
ing to  this  observer,  there  remain  20  per  cent,  of  the 
cases  of  gastric  haemorrhage  which  when  left  un- 
treated die,  which  to  our  mind  cannot  be  regarded 
as  a  negligible  quantity.  Are  there  not  some  cases 
in  which  operation  offers  some  possibility  of  success, 
and  what  are  these  cases  ?  How  can  one  detect  those 
in  which  death  will  ensue  if  only  medical  treatment 
is  followed  ? 

Mayo-Robson  considers  that  the  indication  is  well 
denned  :  operation  for  haemorrhage  should  not 
be  undertaken  until  close  watching  of  the  patient 
shows  that  the  bleeding  continues  and  that  there 
is  imminent  danger  of  death.  From  this  stand- 
point the  operation  is  done  in  extremis,  and  conse- 
quently the  prognosis  is  extremely  poor.  This 
manner  of  regarding  the  question  also  shows  how 
little  confidence  the  English  surgeon  entertained  in 
the  operative  treatment  of  gastric  haemorrhage  in 
general.  Moynihan  likewise  only  resorts  to  opera- 
tion as  a  last  resource.  These  two  eminent  surgeons 
nevertheless  record  a  few  desperate  cases  in  which 
they  were  successful. 

With  them  we  admit  the  following  indication  for 

p  2 


212  SURGICAL  TREATMENT 

operative  interference  in  fulminating  haemorrhage, 
also  accepted  by  the  great  majority  of  surgeons, 
namely,  when  after  a  close  observation  of  the  patient 
it  is  recognised  that  the  bleeding  continues  instead  of 
ceasing  spontaneously,  as  is  usually  the  case,  operation 
should  not  be  postponed. 

The  distinction  is  often  difficult  to  make,  and 
without  careful  observation  it  will  not  always  be 
possible  to  form  an  exact  opinion  on  the  usually 
very  rapid  evolution  of  this  complication  ;  in  fact, 
it  is  clear  that  it  cannot  be  otherwise.  In  order  to 
come  to  a  decision  the  general  impression  given  by 
the  patient — that  is  to  say,  the  "  clinical  sense  "  of 
the  physician — must  weigh  for  much. 

Fortunately,  however,  there  are  other  clearer  signs 
than  those  resulting  from  a  simple  clinical  impression 
— which  at  the  best  must  be  surrounded  by  doubt — 
which  will  sometimes  give  a  clue  to  the  progress  and 
probable  evolution  of  an  acute  gastric  haemorrhage. 
The  most  important  of  all  is  certainly  the  detection 
of  a  concomitant  pyloric  stenosis  with  more  or  less 
energetic  gastric  peristalsis. 

When  the  peristalsis  is  seen  to  appear  in  the 
epigastric  region  ;  when  one  perceives  the  outline 
of  the  stomach  under  the  abdominal  parietes,  as  may 
happen,  although  less  frequently  than  is  commonly 
supposed  ;  when  with  the  hand  one  can  feel  the  organ 
laboriously  endeavouring  to  empty  its  contents,  in 
these  circumstances  there  is  little  prospect  that  the 
haemorrhage  will  spontaneously  subside.  It  will  not 
be  the  few  grammes  of  bismuth,  the  more  or  less 
large  doses  of  perchloride  of  iron,  or  the  external 


REMORRHAGIC  ULCER  218 

applications  like  an  icebag,  that  will  prevent  the 
eroded  vessel  from  bleeding  because  it  is  mobilised 
almost  unceasingly  by  the  rhythmical,  and  often 
inordinate,  contractions  of  the  stomach.  Then 
again,  the  organ  remaining  dilated  and  unable  to 
contract  upon  itself,  the  vessel  naturally  remains 
gaping,  and  the  same  conditions  are  present  that 
are  met  with  in  a  post-partum  haemorrhage,  when  the 
remains  of  membranes  or  the  placenta  prevent  the 
uterus  from  contracting. 

Gastric  lavage,  with  or  without  perchloride  of  iron, 
may  sometimes  render  real  service,  but  unfortunately 
its  effect  is  too  fleeting  to  be  of  use  in  serious  cases. 
Adrenalin  cannot  be  relied  on,  but  there  is  a  prepara- 
tion that  has  now  been  tried  sufficiently  to  justify 
its  use  in  the  cases  under  consideration.  We  refer  to 
coagulen. 

It  is  a  well-known  fact  that  the  coagulation  of 
blood  is  a  complex  process  which,  notwithstanding 
the  numerous  papers  published  on  the  subject,  is 
not  yet  completely  elucidated.  According  to  most 
writers — Bordet,  Delange,  Nolf,  Morawitz — coagula- 
tion is  due  to  the  intervention  of  two  substances. 
The  first,  called  thrombogen  by  Morawitz  or  serozym 
by  Bordet  and  Delange,  is  said  to  exist  in  the  blood 
serum ;  the  second,  called  thrombokinase  by  Mora- 
witz or  cytozym  by  Bordet  and  Delange,  is  said  to  be 
secreted  by  the  blood  platelets. 

When  blood  escapes  from  a  vessel,  the  thrombo- 
kinase existing  in  the  platelets  is  set  free,  and  com- 
bines with  the  thrombogen  of  the  serum  to  form 
thrombin  (fibrin  ferment),  the  active  fibrinogen 


214 


SURGICAL  TREATMENT 


Blood 
serum 


Blood 
platelets 


ferment,  which  provokes  coagulation.     The  following 
sketch  illustrates  the  process  : — 

C  Thrombogen  (Morawitz),      ] 

or 
Serozym  (Bordet-Delange), 

or  Thrornbin 

Plasmozym  (Fuld).  (fibrin 

f  Thrombokinase  (Morawitz),     ferment). 

or 
*  Cytozym  (Bordet-Delange), 

or 

Thrombozym  (Nolf).  • 
According  to  Forgues,  coagulen  is  a  cytozym  in  a 
condition  of  nearly  complete  purity,  the  coagulating 
property  of  which  has  been  demonstrated  clinically 
on  a  large  scale.  In  the  case  of  gastric  haemorrhage 
20  c.c.  of  a  10  per  cent,  solution  may  be  given  per  os, 
and  it  can  also  be  given  intravenously,  the  drug  being 
put  up  for  this  purpose  in  sterile  ampoulae.  Successful 
results  in  severe  haemorrhage  from  ulcer  have  been 
recorded  recently  by  Brasstig  (two  cases)  and  Meyer 
(one  case). 

Lastly,  there  is  another  circumstance  which  may 
also  give  indications  relative  to  the  evolution  of  a 
haemorrhage  ;  we  refer  to  the  character  of  the  ulcer. 
One  should  invariably  endeavour  to  ascertain  the 
previous  evolution  of  the  affection.  This  datum  may 
be  of  great  usefulness,  because  it  is  known  that  cir- 
cumscribed, non-indurated  acute  ulcers  give  rise  to 
very  free  haemorrhage,  often  of  a  disquieting  nature, 
but  which  is  rarely  fatal.  The  contrary  is  true  of 
chronic  ulcer  with  indurated  edges. 


ILEMORRHAGIC  ULCER  215 

To  conclude,  we  would  say  that  the  indication  for 
operation  cannot  be  established  by  any  fixed  rule 
based  on  the  total  statistics,  comprising  acute  ulcers 
in  a  state  of  gastrotaxis  and  chronic  ulcers.  The 
haemorrhage  is  to  be  considered  separately  according 
to  the  type  of  ulcer.  Otherwise  put,  the  operative 
indication  does  not  depend  upon  the  quantity  of 
blood  lost,  but  upon  the  source  of  the  haemorrhage. 

In  acute  ulcer,  particularly  in  young  females,  the 
haemorrhage  will  almost  always  cease  spontaneously, 
so  that  an  interference  will  not  be  likely  to  control  it, 
because  these  small  ulcers  or  erosions  of  the  mucosa 
escape  the  most  minute  search.  Consequently,  since 
spontaneous  cure  is  the  rule  and  operation  uncertain, 
it  is  evident  that  abstention  is  the  better  practice.  In 
chronic  ulcer  in  the  male,  even  in  young  men  or  elderly 
subjects,  the  conditions  are  reversed.  The  haemorrhage 
has  little  tendency  to  stop,  and  an  operation  will  quickly 
lead  to  its  source.  Therefore  the  surgeon  should  act 
and  not  remain  in  a  state  of  vague  uncertainty.  These 
cases  must  be  dealt  with  surgically. 

Choice  of  the  Procedure. — The  operative  procedures 
devised  for  haemorrhage  in  gastric  ulcer  are  very 
numerous,  and  each  possesses  very  distinct  indications. 
Each  one  presents  advantages  and  disadvantages  in 
regard  to  the  special  circumstances  in  which  the  haemor- 
rhage takes  place,  the  importance  of  which  cannot  be 
too  greatly  exaggerated  given  the  gravity  of  these  cases . 
Above  all  should  one  be  mistrustful  of  fixed  rules 
dictated  by  a  series  of  fortunate  cases  published  by  a 
single  writer  and  derived  from  his  personal  practice. 
On  the  contrary,  it  is  absolutely  necessary  to  examine 


216  SURGICAL  TREATMENT 

the  anatomical  and  physiological  circumstances  sur- 
rounding the  principal  episode,  namely,  the  haemor- 
rhage. At  first  sight  the  problem  does  not  appear  to 
be  particularly  intricate,  and,  in  order  to  fulfil  one  of 
the  primordial  rules  of  surgery,  ligature  is  thought  of 
as  soon  as  the  case  is  one  of  haemorrhage.  Such  would 
be  the  logical  operation  theoretically  considered.  But 
it  is  quite  otherwise  in  practice. 

In  point  of  fact,  the  accessory  circumstances 
assume  in  the  case  under  consideration  a  capital 
importance,  and  this  is  all  the  greater  because  the 
operation  will  invariably  be  one  of  extreme  urgency, 
performed  on  a  subject  in  a  state  of  advanced 
physical  exhaustion,  therefore  incapable  of  with- 
standing a  prolonged  surgical  act.  Even  more  than  in 
most  surgical  emergencies  the  end  to  be  attained  must 
be  reached  surely  and  without  loss  of  time.  Any  delay, 
any  hesitation,  may  radically  compromise  the  result. 
All  the  procedures  should  be  familiar  to  the  ope- 
rator, as  well  as  their  advantages  in  each  particular 
case,  because  a  choice  can  only  be  made  with  the 
stomach  in  the  hand.  The  various  operative  pro- 
cedures that  have  up  to  the  present  time  been 
employed  in  acute  haemorrhage  are  : — 

Gastrotomy. 

Excision  of  the  ulcer. 

Partial  excision  of  the  stomach. 

Curettage  and  cauterisation  of  the  ulcer. 

Burying  the  ulcer. 

Ligature  of  the  bleeding  vessel. 

Gastroenterostomy. 

Jejunostomy. 


ELEMOBRHAGIC  ULCER  217 

We  shall  now  attempt  to  outline  in  what  circum- 
stances each  one  of  these  procedures  should  be  pre- 
ferred, but  before  so  doing  it  appears  necessary  to 
remark  that  several  of  them  are  to  be  preceded  by  a 
preliminary  operative  step  to  which  little  reference 
has  been  made  ;  we  refer  to  gastrotomy. 

Gastrotomy. — A  bleeding  ulcer  is  often  devoid  of 
any  sign  on  the  external  aspect  of  the  stomach  that 
will  permit  the  surgeon  to  locate  the  lesion.  This  is 
especially  true  in  haemorrhage  due  to  an  acute  ulcer 
or  even  an  exulceratio  simplex. 

These  haemorrhages  are  not  supposed  to  be  suitable 
for  operation,  since  in  the  majority  of  cases  they  cease 
spontaneously.  However,  certain  circumstances  or 
symptoms  may  incite  the  surgeon  to  act,  who  then 
finds  himself  under  the  obligation  of  exploring  the 
internal  aspect  of  the  stomach,  since  no  trace  of  the 
lesion  can  be  detected  on  the  external  aspect  of  the 
organ.  This  can  only  be  done  by  gastrotomy. 

There  are  other  cases  in  which  the  surgeon  has  been 
obliged  to  resort  to  gastrotomy  because  intimate 
adhesions  have  developed  binding  the  ulcer  to  some 
parenchymatous  viscus,  such  as  the  liver  or  pancreas. 
The  latter  organ  is  the  one  most  frequently  involved, 
and  by  close  adhesion  to,  or  even  forming  the  fundus 
of,  the  ulcer,  prevents  dealing  with  a  profuse  haemor- 
rhage from  the  external  surface  of  the  stomach.  Free- 
ing the  organ  from  the  adhesions  seriously  compli- 
cates the  operation,  which,  in  order  to  have  any 
chance  of  being  successful,  must  be  conducted  with 
great  rapidity.  In  these  circumstances,  to  save  time, 
the  ulcer  may  be  reached  by  way  of  the  interior  of 


218  SUKGICAL  TREATMENT 

the  stomach  by  approaching  it  through  a  temporary 
gastrotomy.    This  is  not  merely  an  exploratory  pro- 
cedure, but  is  in  reality  a  necessary  step  in  the  opera- 
tion for  the  direct  treatment  of  the  haemorrhage.    As 
to  the  danger  of  infection  of  the  peritoneal  cavity 
from  gastrotomy  in  the  cases  under  consideration,  it 
may  be  said  that  in  our  hands,  as  well  as  those  of 
other  surgeons  who  have  resorted  to  it — Rodman, 
Moullin,  Monprofit,  not  to  mention  others — no  unto- 
ward   result  has  occurred,  and  we  believe  that  it 
should  be  more  frequently  done  than  it  has  generally 
been  so  far.     But  we  would  add  that  in   our  ex- 
perience at  least  gastrotomy  will  not  always  expose 
the  ulcer  which  is  bleeding.     Cases  are  far  from  in- 
frequent in  which,  even  on  the  autopsy  table,  the 
ulcer  cannot  be  discovered  either  on  account  of  its 
diminutive  size  or  because  it  is  hidden  in  a  fold  of 
the  mucosa. 

We  would  also  mention  in  regard  to  gastrotomy 
the  introduction  into  the  gastric  cavity  of  a  small 
endoscopic  lamp.  By  transillumination  the  source 
of  the  bleeding  is  searched  for.  This  diagnostic 
measure  is  hardly  employed,  excepting  by  its  inventor, 
Rovsing.  It  does  not  appear  to  be  particularly 
practical,  and  certainly  can  only  be  employed  in  cases 
of  acute  ulcer,  and  these  are  just  the  cases  which  are 
useless  to  operate  on.  Occasionally  transillumina- 
tion of  the  stomach  might  be  serviceable. 

Consequently  gastrotomy  does  not  seem  to  us  to 
possess  much  value  as  an  exploratory  operation, 
because  of  the  following  two  reasons  :  (1)  that  a 
haemorrhage  resulting  from  an  acute  ulcer,  that  is 


ILEMORRHAGIC  ULCER  219 

to  say,  a  lesion  giving  no  sign  on  the  external  aspect 
of  the  stomach,  is  hardly  suitable  for  operation,  and 
(2)  even  a  very  large  incision  in  the  stomach  does 
not  always  expose  the  source  of  the  bleeding. 

On  the  other  hand,  all  writers  who  have  resorted 
to  gastrotomy  as  a  preliminary  step  in  the  direct 
treatment  of  the  ulcer  warmly  recommend  it.  It 
is  especially  useful  when  the  ulcer  has  penetrated  into 
the  liver  or  pancreas,  therefore  in  the  less  acutely 
developing  types  of  the  lesion.  We  have  been  dis- 
inclined to  include  gastrotomy,  in  spite  of  its  import- 
ance, among  the  procedures  employed  for  gastric 
ulcer,  as  it  has  no  inherent  therapeutical  effect.  It 
offers  a  real  interest,  however,  and  it  also  has  the 
advantage  of  giving  exit  to  the  blood  clots,  which, 
unless  removed  from  the  stomach,  give  rise  to  putre- 
faction in  the  gastro-intestinal  tract.  This,  of  course, 
is  merely  a  secondary  advantage,  but  it  merits  being 
referred  to. 

Resection  and  Excision. — Not  so  many  years  ago 
resection  of  the  stomach  was  regarded  as  too  trau- 
matic to  be  employed  in  acute  gastric  haemorrhage. 
The  progress  made  in  technique  as  well  as  greater 
experience  acquired  has  resulted  in  the  treatment  of 
these  cases  by  resection,  sometimes  even  very  exten- 
sive. Haberer  presented  in  1919  a  series  of  cases  in 
which  pylorogastrectomy  had  given  him  excellent 
results.  The  majority  of  his  cases  were,  nevertheless, 
in  a  miserable  condition  at  the  time  operation  was 
resorted  to. 

It  is  certain  that  resection  is  the  ideal  treatment, 
because  it  is  carried  out  in  healthy  tissue,  while  at 


220  SURGICAL  TREATMENT 

the  same  time  the  haemorrhage  and  ulcer  are  dealt 
with,  so  that  recurrence  is  avoided.  In  the  majority 
of  cases  the  best  type  of  resection  will  be  pylorectomy 
if  the  ulcer  is  seated  in  the  pylorus,  while  pyloro- 
gastrectomy  is  indicated  when  the  lesion  is  on  the 
lesser  curvature.  It  goes  without  saying  that,  should 
one  find  the  ulcer  on  the  anterior  aspect  of  the  organ, 
simple  excision  of  the  lesion  is  all  that  is  necessary, 
but  such  cases  are  exceptional. 

Resection  should  be  reserved  for  localised  ulcer 
without  extensive  penetration  into  the  liver  or  pan- 
creas. In  fact,  one  cannot  undertake  this  long  and 
laborious  procedure  in  patients  such  as  have  been 
described  in  this  chapter.  As  we  pointed  out  when 
speaking  of  resections  from  the  view-point  of  the 
ulcer,  the  surgeon  must  be  distinctly  sure  of  his 
dexterity,  backed  by  experience,  when  undertaking 
this  operation.  What  some  may  attempt  others  must 
abstain  from. 

It  should  also  be  mentioned  that  extensive  pylorec- 
tomy has  been  done  in  cases  of  gastrotaxis,  with  the 
idea  that  these  small  ulcers  or  erosions  giving  rise  to 
the  bleeding  are  almost  invariably  seated  near  the 
pylorus.  Such  cases  are  still  too  few  in  number  to 
form  an  idea  as  to  the  value  of  this  operation  in  these 
circumstances.  We  have  employed  it  in  one  case 
with  a  result  that  can  be  regarded  as  good,  the  patient 
having  remained  five  years  without  any  return  of  the 
symptoms. 

Curettage  and  Cauterisation. — When  an  ulcer  is  too 
adherent  to  be  mobilised  and  excised,  attempts  have 
been  made  by  some  to  deal  with  the  haemorrhage  by 


ILEMORRHAGIC  ULCER  221 

cauterisation.  This  is  done  with  the  electric  or  thermo- 
cautery  after  a  gastrotomy  opening  has  been  made. 
This  procedure  has  been  very  infrequently  employed, 
and  can  only  be  regarded  as  a  makeshift  when  ana- 
tomical conditions  do  not  admit  of  other  measures, 
because  cauterisation  is  a  too  uncertain  method  of 
haemostasis  to  offer  any  security  in  a  loss  of  blood  so 
extensive  as  that  which  occurs  in  acute  gastric 
haemorrhage.  Its  inherent  risks  are  also  too  great 
for  it  to  be  currently  used,  so  that  it  can  never  be 
other  than  an  exceptional  procedure,  reserved  for 
very  infrequent  and  special  occasions. 

These  exceptions  to  its  use  are  cases  where  the  ulcer 
is  fixed  deeply  down  in  the  abdominal  cavity,  as  in 
ulcer  of  the  lesser  curvature,  or  on  an  adherent 
posterior  stomach  wall,  or  when  the  lesion  penetrates 
into  the  pancreas.  There  can  never  be  any  question 
of  employing  excision  of  the  ulcer  for  the  reasons 
exposed  above  except  in  extraordinary  circum- 
stances. This  radical  operation  would  be  infinitely 
too  long  and  laborious.  Oftentimes  other  procedures 
are  not  much  more  tempting.  Ligature  of  the 
bleeding  vessel,  even  mediate  ligature,  an  uncertain 
procedure,  as  we  shall  show,  is  quite  as  laborious, 
and,  besides,  cannot  be  done  in  the  indurated,  callous, 
periulcerous  mass.  These  degenerated  tissues  pre- 
vent burying  the  ulcer  as  well,  while  gastroenteros- 
tomy  has  not  always  a  sufficiently  rapid  action 
to  arrest  the  haemorrhage. 

In  these  embarrassing  cases  the  operator  will  some- 
times be  fortunate  enough  to  produce  the  formation 
of  a  vascular  thrombus  by  the  use  of  the  cautery  ;  and, 


222  SURGICAL  TREATMENT 

no  matter  how  doubtful  the  result,  he  may  be  entitled 
to  have  recourse  to  this  method,  which  has  occasion- 
ally been  successful  when  other  procedures  have  been 
attempted  in  vain. 

With  a  view  to  increase  the  action  of  cauterisation, 
some  surgeons  first  curette  the  fundus  of  the  ulcer, 
hoping  by  this  means  to  act  beyond  the  limits  of  the 
indurated  tissues  and  thus  obtaining  a  more  secure 
haemostasis.  No  opinion  can  be  formed  in  regard 
to  this  procedure,  as  it  has  been  too  infrequently 
resorted  to,  but  we  fail  to  see  how  it  can  offer  any 
particular  advantage. 

Infolding  of  the  Ulcer. — As  a  convinced  partisan 
of  expectant  treatment  in  cases  of  severe  haemorrhage, 
Moynihan  is  content  with  infolding  or  burying  the 
ulcer  when  he  is  obliged  to  treat  the  case  surgically. 
When  the  source  of  the  haemorrhage  has  been  dis- 
covered, the  operation  consists  of  making  a  purse- 
string  suture  around  the  ulcer,  forming  an  en  masse 
ligature.  One  or  several  layers  of  purse-string  sutures 
may  be  made,  and  in  this  way  all  the  vessels  passing 
within  the  area  of  the  ligature  are  included  in  its 
grasp,  while  at  the  same  time  the  serosa  forms  solid 
adhesions  around  the  plication.  The  suture  must  be 
sufficiently  deep  to  include  at  least  the  muscularis 
and  submucosa,  in  which  the  large  vessels  lie.  The 
entire  thickness  of  the  gastric  wall  may  be  comprised 
in  the  ligature. 

Usually  performed  from  the  external  aspect  of  the 
stomach,  the  purse-string  ligature  may  be  also  applied 
on  the  internal  surface  of  the  stomach  through  a 
gastrotomy  opening. 


ILEMORRHAGIC  ULCER  223 

This  procedure  possesses  the  great  advantage  of 
being  both  simple  and  rapid,  and  offers  greater 
security  than  simple  ligature  of  a  large  vessel  sup- 
posed to  be  the  source  of  the  haemorrhage.  Unfor- 
tunately, as  Moynihan  has  pointed  out,  this  suture 
cannot  always  be  employed.  This  is  especially  the 
case  when  the  ulcer  is  surrounded  by  an  area,  even 
slight,  of  indurated  tissue,  and  this  for  two  reasons  : 
(1)  the  ligature  will  cut  through,  and  (2)  therefore 
it  cannot  be  made  sufficiently  tight  to  produce 
plication  of  the  tissues,  which  are  frequently  as  hard 
as  cartilage. 

Hence  it  is  that  if  this  procedure  is  to  be  employed 
it  is  essential  that  the  ulcer  shall  not  have  produced 
any  very  extensive  or  marked  change  in  the  peripheral 
structures. 

But  there  are  yet  other  circumstances  which  render 
this  procedure  impracticable.  In  the  first  place,  it 
must  be  given  up  when  the  ulcer  presents  any  adhe- 
sions whatsoever,  and  particularly  when  these  adhe- 
sions bind  the  stomach  intimately  to  the  liver  or 
pancreas.  As  we  have  said,  the  ulcer  can,  if  abso- 
lutely necessary,  be  approached  by  the  internal 
surface  of  the  stomach,  but  these  adhesions  com- 
pletely prevent  the  walls  from  being  brought  together, 
so  that  the  effectiveness  of  the  operation  is  illusive. 

Secondly,  according  to  the  site  of  the  ulcer, 
infolding,  like  excision,  may  result  in  a  very  important 
deformity  of  the  stomach.  For  example,  near  the 
pylorus  such  deformity  may  cause  a  more  or  less 
complete  stenosis,  a  fact  which  must  never  be  lost 
sight  "of. 


224  SURGICAL  TREATMENT 

Ligature. — Under  this  general  heading  are  com- 
prised those  operations  which  differ  as  much  in  their 
technique  as  they  do  in  their  manner  of  action.  A 
ligature  may  be  directly  applied  on  the  vessel  giving 
rise  to  the  loss  of  blood,  over  the  lesion  of  con- 
tinuity in  its  walls.  This  direct  ligature  requires 
anatomical  conditions  rarely  met  with  in  practice. 
The  ligature  may  also  be  mediate,  that  is  to  say, 
placed  directly  on  the  isolated  vessel,  not  at  the  site 
of  the  bleeding,  but  at  a  distance  from  it.  It  can  be 
single  or  double  according  to  circumstances. 

Lastly,  the  ligature  may  be  made  to  include  the 
vessel  and  ambiant  tissues,  in  which  case  the  ligature 
is  mediate  and  is  usually  employed  when  adhesions 
or  callous  tissue  surrounding  the  ulcer  completely 
prevent  the  vessel  from  being  found  and  exposed. 

The  procedure  by  far  the  best  known  is  unques- 
tionably immediate  ligature,  and  is,  at  the  same  time, 
the  most  logical  and  the  one  most  likely  to  give 
certain  results.  But  unfortunately  the  contra-indi- 
cations  for  this  procedure  are  so  numerous  that  it  can 
only  be  employed  in  very  rare  cases.  In  point  of 
fact,  if  it  is  to  be  resorted  to  with  any  chance  of 
success,  several  conditions,  which  are  only  infre- 
quently present,  must  obtain.  Especially  must  one 
be  able  to  exactly  recognise  the  vessel  giving  rise 
to  the  haemorrhage.  When  once  discovered,  the 
vessel  should  be  readily  accessible ;  therefore  it  must 
not  be  embedded  in  adhesions  or  surrounded  by  a 
coat  of  callous  tissue.  Consequently  the  surgeon 
must  keep  outside  of  the  area  of  lardaceous  tissue 
surrounding  the  ulcer ;  and  if  this  area  is  at  all  exten- 


ILEMORRHAGIC  ULCER  225 

sive,  it  is  to  be  feared  that  a  ligature,  even  when 
double,  will  not  prevent  the  blood  from  reaching  the 
parts  by  the  very  numerous  vascular  anastomoses  of 
the  stomach. 

Cases  are  certainly  rare  in  which,  like  the  one 
reported  by  Rossoni,  the  surgeon  has  been  fortunate 
enough  to  discover  a  small,  non-indurated  ulcer 
seated  exactly  on  the  vessel  which  had  become 
eroded,  and  where  a  simple  ligature  sufficed  to 
control  the  bleeding.  It  must  be  clearly  remembered 
that  in  the  majority  of  cases  one  will  be  operating 
on  chronic  ulcers,  so  that  one  must  be  prepared  to 
encounter  indurated  tissues  surrounded  by  adhesions 
which  do  not  even  allow  one  to  discover  the  bleeding 
vessel.  And  the  exposure  of  such  a  vessel  is  merely 
a  dream.  If  it  cannot  be  reached  from  the  outside  of 
the  stomach,  gastrotomy  must  not  be  counted  on  for 
the  purpose  of  finding  it  inside  the  stomach,  especially 
when  the  ulcer  is  adherent  to  the  adjacent  parts. 

As  to  distant  ligatures,  they  usually  offer  very 
slight  guarantee,  so  that  direct  ligature,  which 
might  at  first  be  regarded  as  the  most  simple  and 
logical  procedure,  has  only  very  rare  indications. 

On  the  contrary,  mediate  ligature  may  be 
attempted  much  more  frequently.  When  the  vessel 
is  surrounded  by  tissues  even  of  a  friable  nature,  the 
lumen  of  the  artery  can  be  sufficiently  occluded  to 
stop  the  haemorrhage  when  the  ligature  is  made 
to  encircle  it.  Therefore  it  is  not  necessary  to  apply 
it  at  a  distance  from  the  ulcer.  It  can  be  applied 
directly  around  the  ulcer,  and  a  few  U-shaped  sutures 
will  give  all  the  required  security. 


226  SURGICAL  TREATMENT 

Briefly  stated,  this  ligature  is  merely  the  first  step 
in  infolding  the  ulcer.  The  latter  procedure  is 
clearly  surer,  but,  as  we  have  said,  it  can  only  be 
employed  when  the  induration  is  both  circumscribed 
and  mobilisable,  while  in  the  case  of  mediate  ligature 
this  can  be  done  in  any  circumstances,  even  through 
adhesions,  providing,  of  course,  that  these  are  not  too 
dense. 

It,  nevertheless,  has  the  disadvantage  of  being  a 
delicate  operation,  necessitating  much  manual  dex- 
terity on  the  surgeon's  part  in  order  to  tie  the 
ligature  in  such  a  way  as  not  to  cut  through  the 
very  friable  tissues,  and  yet  have  it  tight  enough 
for  the  control  of  the  haemorrhage.  The  condition 
is  the  same  as  in  suture  of  the  liver.  Here  also 
mediate  ligatures  are  placed  in  the  friable  and  rather 
rigid  hepatic  parenchyma,  which  offers  no  resistance 
to  the  ligature.  This  procedure  has  nevertheless 
been  generally  adopted,  and  gives  unquestionably 
good  results.  Why  then  should  it  not  be  more 
commonly  used  in  haemorrhage  from  gastric  ulcer 
when  other  procedures,  especially  infolding,  cannot 
be  practised  for  one  reason  or  another  ? 

Gastroenterostomy. — This  procedure  is  so  well 
defined  in  all  gastric  affections  that  several  observers 
refuse  to  admit  that  an  operation  which  can  render 
such  varied  and  multiple  services  is  in  reality  effec- 
tive. The  effectiveness,  particularly  as  it  relates  to 
acute  gastric  haemorrhage,  is  doubted  by  many.  It 
must  be  admitted  that  there  is  some  little  difficulty 
in  explaining  the  mechanism  of  its  action,  and  that 
in  cases  where  the  outcome  is  successful  it  may  be 


H^MORRHAGIC  ULCER  227 

well  asked  to  what  extent  the  happy  control  of  the 
haemorrhage  depends  upon  this  operation  and  whether 
or  not  it  is  merely  a  fortuitous  coincidence.  It  is 
frequently  difficult  to  judge  correctly  :  the  cases  in 
which  the  haemorrhage  ceases  spontaneously  are  too 
common  for  one  to  be  able  to  deny  the  possibility  of 
such  a  coincidence  ;  on  the  other  hand,  the  very 
contradictory  results  obtained  by  various  surgeons 
are  not  disposed  to  enlighten  us  on  this  subject. 

Hence  such  varied  opinions  of  different  surgeons  in 
regard  to  the  value  of  gastroenterostomy  in  serious 
gastric  haemorrhage.  Some  look  upon  it  as  the  proce- 
dure of  choice  ;  others,  like  Mayo-Robson,  recom- 
mend it  in  the  majority  of  cases  of  severe  haemorrhage, 
that  is  to  say,  when  the  subject  is  no  longer  in  a 
condition  to  withstand  a  long  traumatising  opera- 
tion ;  others,  on  the  contrary,  having  been  unsuc- 
cessful, absolutely  deny  the  possibility  of  any  effect 
being  derived  from  this  procedure. 

The  principal  arguments  of  the  latter  are  as 
follows  : — 

(1)  The  manner  of  action  of  gastroenterostomy 
cannot  be  explained. 

(2)  The  generally  recognised  action  in  cases  of 
ulcer  is  too  indirect  and  is  too  long  in  developing  for 
the  control  of  an  acute  haemorrhage  whose  evolution 
is  so  rapid. 

(3)  Even  if  an  immediate  result  is  obtained,  one 
must    invariably    anticipate    more    or   less    distant 
recurrences. 

We  shall  attempt  to  show  how  the  action  of  gastro- 
enterostomy can  be  explained,  but  we  would  say  at 

Q2 


228  SURGICAL  TREATMENT 

once  that  the  explanations  offered  are  hardly  more 
than  hypotheses. 

The  effect  of  gastroenterostomy  can  clearly  only  be 
an  indirect  one,  and  there  is  some  difficulty  in 
supposing  it  to  be  rapid  for  the  control  of  the  bleed- 
ing. We  have  already  explained  the  happy  influence 
exercised  by  this  operation  over  the  cicatrisation  of 
the  ulcer,  but  this  slow  progressive  healing  cannot  be 
compared  with  the  sudden  arrest  of  an  accident  whose 
outcome  is  occasionally  so  rapidly  fatal. 

There  are,  nevertheless,  cases  in  which  gastro- 
enterostomy  may  exercise  a  very  prompt  effect, 
although  an  indirect  one,  and  in  which  the  operation 
seems  to  us  particularly  indicated.  This  is  when  the 
ulcer,  the  source  of  the  haemorrhage,  provokes  either 
anatomically  or  physiologically — that  is  to  say,  by 
reflex  action — a  pyloric  stenosis.  We  have  already 
remarked  that  in  these  cases  the  dilated  stomach  tries 
to  expel  its  contents  by  peristaltic  movements  so 
marked,  in  fact,  that  they  may  be  perceived  under  the 
abdominal  wall.  The  distended  gastric  walls  are 
unable  to  come  together,  and  it  is  natural  that  the 
eroded  vessels  should  remain  open.  This  is  one  of 
the  most  important  factors  of  the  gravity  of  gastric 
haemorrhage. 

If,  therefore,  by  so  simple  an  operation  as  gastro- 
enterostomy,  gastric  drainage  is  created,  and  if  from 
this  fact  the  organ  can  contract  on  itself,  the  unfavour- 
able circumstances  in  which  haemorrhage  is  produced 
are  done  away  with.  Does  this  mean  that  gastro- 
enterostomy  stops  the  bleeding  ?  We  do  not  think 
so,  and  we  believe  that  it  is  more  logical  to  assume 


H^MORRHAGIC  ULCER  229 

that  this  operation  facilitates  the  nature  of  its  task, 
which  is  to  overcome  this  complication. 

Treatment  of  gastric  haemorrhage  by  gastroenteros- 
tomy  cannot,  we  think,  be  regarded  as  truly  effec- 
tive, and  it  is  for  this  reason  that  we  find  so  many 
varied  opinions  and  contradictory  evidence  in  regard 
to  the  results  obtained.  The  operation  having  but  a 
limited  action,  must  leave  much  to  fortuitous  circum- 
stances, and  this  could  not  be  otherwise. 

Now  comes  the  essential  point.  Should  this  action, 
although  limited,  be  regarded  as  sufficiently  impor- 
tant to  advocate  an  operation  that  is  always  serious, 
given  the  precarious  state  in  which  these  patients 
are  when  operation  has  been  decided  on  ?  The 
opinion  of  numerous  surgeons,  particularly  those 
who  have  had  a  large  experience  in  gastric  surgery, 
is  distinctly  affirmative.  The  first  element  in  the 
treatment  is  to  place  the  stomach  in  absolute  rest, 
and  how  can  this  be  done  when  the  organ  is  unable  to 
rid  itself  of  its  contents  if  it  is  not  by  a  gastroenteros- 
tomy  stoma  ?  The  operation  fulfils  the  primordial  rule 
in  the  treatment  of  gastric  haemorrhage,  which  consists 
of  avoiding  any  excitation  or  work  of  the  organ. 

Now,  among  the  cases  in  which  the  indication  for 
operating  is  admitted,  the  vast  majority  are  accom- 
panied by  pyloric  stenosis,  hence  the  benefit  derived 
from  gastroenterostomy. 

Lastty,  the  final  argument  of  the  opponents  of 
gastroenterostomy  is  that  this  operation,  even  if  it 
controls  the  haemorrhage,  does  not  prevent  recurrences. 
Many  are  the  patients  who,  we  know,  have  died  from 
a  gastric  haemorrhage  after  a  variable  lapse  of  time 


230  SURGICAL  TREATMENT 

following  gastroenterostomy.  Some  instances  are 
too  well  known  for  us  to  insist  further ;  and  we  will 
simply  mention  the  celebrated  cases  of  Garre, 
Kroenlein  and  Hartmann,  which  have  served  as  the 
basis  for  study  and  interesting  discussion.  From 
what  we  have  said  of  the  bad  results  of  this  operation 
the  repetition  of  the  haemorrhage  should  not  surprise. 
The  operation  does  not  eliminate  the  ulcer,  neither 
does  it  cure  it ;  it  merely  places  it  in  favourable  con- 
ditions for  cure,  but  a  certain  length  of  time  will  be 
required  for  so  stubborn  a  lesion  to  become  cicatrised. 
It  is,  therefore,  natural  that  during  this  time  a 
haemorrhage  may  occur,  even  a  very  profuse  or  fatal 
one. 

Consequently  it  becomes  more  and  more  evident 
that  gastroenterostomy  is  not  an  absolutely  sure 
operation,  one  that  can  inspire  confidence  ;  never- 
theless it  is  one  of  the  procedures  most  commonly 
employed  in  li£emorrhage,  even  when  this  is  acute. 
The  reasons  why  it  is  preferred  in  certain  cases  to 
other  procedures  are  : — 

(1)  It  can  always  be  carried  out,  and 

(2)  It  is  the  most  simple  and  rapid  operation  with- 
out much  traumatic  effect,  and  can  be  done  without 
general  narcosis. 

We  have  endeavoured  to  show  how  each  of  the 
procedures  requires  special  circumstances,  such  as  a 
fortunate  site  of  the  ulcer,  absence  of  adhesions,  a 
limited  area  of  diseased  tissue,  etc.,  which  make 
these  operations  excellent,  but  always  with  excep- 
tions. Other  than  for  some  very  rare  cases  in  which  the 
stomach  is  completely  invaded  by  the  infiltration,  the 


ILEMORRHAGIC  ULCER  231 

necessary  space  will  always  be  found  for  placing  the 
stoma  in  a  proper  position.  Thus  the  cases  are 
extremely  rare  in  which,  after  the  abdomen  is 
opened,  it  will  be  found  that  the  procedure  is  not 
applicable. 

Finally,  the  chief  advantage  of  gastroenterostomy 
is  that  its  technique  is  simple  and  rapidly  carried  out. 
This  is  clearly  a  capital  advantage  when  the  minimum 
state  of  resistance  offered  by  subjects  with  serious 
gastric  haemorrhage  is  taken  into  consideration.  We 
have  already  remarked  how  dangerous  are  the 
so-called  ideal  operations,  such  as  excision  or  infolding 
of  the  ulcer.  Their  principal  danger  resides  in  the 
length  of  time  required  for  carrying  them  out,  as  well 
as  the  shock  ensuing  from  their  traumatising  action. 
With  gastroenterostomy  these  risks  are  reduced  to 
their  minimum,  especially  if  a  Murphy  button  is  used, 
when  it  should  be  completed  in  less  than  ten  minutes. 
The  parts  are  not  handled  ;  hence  there  is  little  or  no 
trauma  inflicted  on  the  sympathetic  nerve  filaments. 
If  the  patient's  state  centra-indicates  general 
narcosis,  block  anaesthesia  is  quite  sufficient,  even 
in  a  conscious  and  weak  subject.  -  Such  are,  in  our 
experience,  the  most  evident  advantages  of  gastro- 
enterostomy, and,  as  Mayo-Robson  has  said,  it  can 
be  employed  in  the  most  desperate  cases. 

But  we  cannot  insist  too  strongly  that  gastro- 
enterostomy must  never  be  considered  an  operation 
giving  certain  results  ;  it  is  far  from  sufficing  in  all 
cases.  It  may  be  made  more  successful  by  associating 
a  complementary  operation  with  it,  such  as  exclusion 
of  the  pylorus  or,  better  still,  the  ulcer,  as  von  Eisels- 


232  SUEGICAL  TKEATMENT 

berg,  Jonnesco  and  others  have  particularly  recom- 
mended. In  this  way,  the  ulcer  being  separated  from 
the  remainder  of  the  stomach,  the  stomach  is  placed  in 
complete  rest,  which  singularly  facilitates  the  control 
of  the  haemorrhage.  The  procedure  is,  however,  not 
absolutely  simple,  and  takes  away  the  principal  advan- 
tage of  gastroenterostomy,  namely,  its  rapid  execu- 
tion and  the  small  amount  of  trauma  inflicted.  It 
may  even  be  so  complicated  and  laborious  that  it 
comes  close  to  excision  without  giving  as  much 
security  in  respect  to  the  future.  In  certain  cases 
it  has  rendered  unquestionable  service,  but  it  must 
be  recognised  that  this  has  been  in  cases  generally 
benign,  with  a  slower  and  more  chronic  evolution, 
all  of  which  is  quite  another  matter. 

To  be  brief,  we  would  say  that  gastroenteros- 
tomy is  one  of  the  most  frequently  performed  opera- 
tions for  acute  gastric  haemorrhage,  although  it  does 
not  give  as  much  security  as  other  methods.  It  is 
particularly  indicated  when  the  ulcer,  the  source  of  the 
bleeding,  is  seated  in  the  pylorus  or  prepyloric  region 
and  has  produced  a  stenosis.  Other  than  in  these 
cases,  no  great  confidence  can  be  placed  in  it ;  but,  for 
all  that,  it  is  the  most  employed  of  all  the  procedures, 
because  it  is  the  least  traumatising,  and  in  certain 
cases  it  offers  the  only  chance  of  saving  life,  when  in 
particular  the  anatomical  conditions  are  such  that  no 
other  procedure  can  be  resorted  to. 

Jejunostomy. — Eecommended  by  Maydl  and  von 
Eiselsberg  for  the  treatment  of  serious  forms  of  ulcer, 
Jejunostomy  has  been  employed  by  these  surgeons 
successfully  in  cases  of  gastric  haemorrhage.  It 


ILEMORRHAGIC  ULCER  238 

places  the  stomach  in  absolute  rest,  while  at  the  same 
time  sufficient  food  can  be  taken.  Particularly 
recommended  in  recurring  gastric  haemorrhage  or  in 
chronic  haemorrhage,  it  has,  according  to  the  general 
consensus  of  opinion,  but  little  effect  in  cases  of  acute 
haemorrhage.  Its  action  is  still  more  indirect  than 
that  possessed  by  gastroenterostomy  without  offering 
the  same  various  advantages  as  the  latter  operation. 
Yet,  for  all  that,  Gauwdcheff,  who  has  written  a  very 
excellent  thesis  on  this  subject,  recommends  jejunos- 
tomy.  He  is  unquestionably  right,  because  there  are 
cases  in  which  the  extent  of  the  lesion,  the  adhesions 
and  the  poor  general  state  of  the  subject  are  all 
contra-indications  for  the  other  operative  procedures. 
Cases  are,  perhaps,  relatively  rare  in  which  jejunos- 
tomy  has  been  employed ;  but  this  is  not  a  valid  reason 
why  it  should  be  regarded  as  a  procedure  of  exception. 
On  the  contrary,  we  are  of  the  opinion  that  its  indica- 
tions should  be  broadened,  especially  in  cases  of 
serious  gastric  haemorrhage. 

Of  all  these  procedures,  each  presenting  advan- 
tages and  disadvantages,  which  is  to  be  preferred  ? 
Assuredly  an  exclusive  preference  cannot  be  given  to 
any  one  of  them.  The  conclusion  is  that,  given  a  case 
of  acute  haemorrhage,  there  is  no  question  of  a  pro- 
cedure of  choice  applicable  to  all  cases  with  a  maxi- 
mum chance  of  success.  Each  case  is  a  law  unto 
itself,  and  cannot  be  dealt  with  by  such  or  such  a 
procedure  whose  choice  is  indicated  by  numerous 
circumstances  which  must  be  seriously  reckoned 
with.  In  particular  the  patient's  general  condition 
should  cause  the  greatest  preoccupation,  because  upon 


234  SURGICAL  TREATMENT 

it  depends  the  possibility  of  employing  certain  pro- 
cedures, the  best  and,  therefore,  giving  the  greatest 
amount  of  security.  Besides,  as  was  said  at  the 
beginning  of  this  chapter,  no  rigorous  plan  of  action 
can  be  decided  on  until  the  ulcer  has  been  distinctly 
exposed  to  both  sight  and  touch.  A  diagnosis  pre- 
liminarily made  will  never  be  sufficiently  exact  in  its 
details  for  the  judicious  selection  of  the  procedure  to 
follow. 

Now,  if  a  rapid  review  be  made  of  the  advantages 
and  disadvantages  presented  by  the  different  methods 
mentioned,  it  will  become  clear  that  excision  of  the 
ulcer  is  the  surest  method,  the  one  giving  the  greatest 
guarantee  against  recurrence  of  the  haemorrhage.  It 
can  only  be  resorted  to  when  the  patient's  general 
condition  is  still  good  enough  to  permit  a  long  and 
occasionally  difficult  operation  to  be  carried  out, 
and  even  in  these  conditions  it  cannot  be  applied 
to  every  case  and  must  be  discarded  whenever  the 
ulcer  has  invaded  the  adjacent  organs  or  when 
already  organised  adhesions  will  give  rise  to  technical 
difficulties. 

Ligature  of  the  bleeding  vessel  may  be  attempted 
in  exceptional  circumstances,  but  little  can  be 
expected  from  this  procedure.  It  is,  however,  well  to 
remember  it,  because  it  may  occasionally  render  con- 
siderable service  on  account  of  its  simplicity  and  the 
security  it  offers  in  the  control  of  the  bleeding. 

Infolding  of  the  ulcer,  which  is  preferable  to 
excision  and  in  many  respects  similar  to  it,  is  a  simple 
procedure  which  is  only  applicable  to  small  ulcers 
with  soft  and  mobile  edges.  Their  mobility  is,  above 


ILEMORRHAGIC  ULCER  235 

all,  important  for  properly  carrying  out  this  tech- 
nique. In  all  other  circumstances  it  is  too  delicate 
and  does  not  offer  sufficient  guarantee  of  success. 

Curettage  of  the  ulcer  with  cauterisation  after  a 
preliminary  gastrotomy  is  useful  only  when  other 
procedures  have  been  found  impracticable,  when,  for 
example,  the  ulcer  is  callous  and  indurated  and  pene- 
trates the  pancreas  or  liver.  The  indications  for  this 
procedure  are  very  limited  when  the  dangers  to  which 
it  exposes  the  patient  are  considered,  as  well  as  the 
small  chance  of  success  it  offers. 

Jejunostomy  is  also  an  operation  generally  little 
recommended.  It  may,  however,  find  its  indication 
when  another  operation  cannot  be  done  on  account  of 
too  extensive  periulcerous  infiltration  and  adhesions, 
and  especially  when  the  patient's  condition  will  not 
withstand  a  long  operative  act. 

Although  perhaps  offering  less  security  than  the 
other  procedures,  gastroenterostomy  fulfils  most  of 
the  conditions  for  success.  When  the  patient's 
state  requires  a  rapid  interference  with  little 
operative  trauma,  when  the  adhesions  or  ulcerous 
infiltration  prevent  the  surgeon  from  acting  more 
directly  and  rapidly  on  the  ulcer,  gastroenterostomy 
is  indicated,  especially  when  the  lesion  is  seated  either 
at  the  pylorus  or  prepyloric  antrum,  or  when  there 
is  an  ulcer  of  the  duodenum. 

If  the  patient's  condition  will  permit  a  longer 
interference,  gastroenterostomy  should  be  completed 
by  exclusion  of  the  pylorus — the  seat  of  the  ulcer — 
or  by  other  more  direct  measures,  such  as  infolding, 
etc.  But  with  all  these  procedures,  with  the  excep- 


236  SURGICAL  TREATMENT 

tion  of  excision,  the  haemorrhage  will  have  been 
controlled,  but  the  ulcer  exists.  Consequently,  if  the 
patient  recovers  from  the  haemorrhage,  treatment  of 
the  ulcer  is  to  be  instituted.  By  this  we  mean  both 
medical  and  surgical  treatment.  When  the  patient 
has  become  more  resistant  and  can  withstand  a  more 
serious  operation,  the  interference  for  the  loss  of 
blood  should  be  completed  according  to  the  circum- 
stances by  a  suitable  operation  for  correcting  the  still 
existing  ulcer. 

Ligature,  infolding  and  cauterisation  do  not  in 
themselves  cure  the  ulcer.  Consequently,  in  certain 
cases  we  must  resort  to  secondary  gastroenterostomy 
or  excision  when  this  is  possible.  In  other  cases 
gastroenterostomy  may  be  completed  by  excision  or 
pyloric  exclusion.  And,  last  but  not  least,  a  severe 
medical  treatment  should  follow  each  and  all  of  these 
surgical  procedures. 

Recurring  Haemorrhage. — Serious  but  not  fatal 
haemorrhages,  dangerous,  especially  on  account  of 
their  recurrence,  which  is  one  of  their  peculiarities, 
are  much  more  common  in  practice  than  fulminating 
haemorrhages.  They  are  more  frequently  suitable  for 
operation,  and  therefore  are  of  special  interest  to  the 
surgeon.  This  special  form  of  haemorrhage  is  most 
frequently  encountered  during  the  evolution  of 
chronic  ulcer,  and  imparts  considerable  gravity  to  it. 
Nevertheless  it  is  met  with  in  other  types  of  ulcer, 
such  as  recurring  ulcer,  a  category  of  ulcer  that 
Julich  in  his  thesis  (1905)  thought  wise  to  place  apart 
from  chronic  ulcer,  under  which  heading  it  had 
generally  been  included.  This  writer  points  out  that 


HjEMORRHAGIC  ULCER  237 

one  of  the  chief  symptoms  which  distinguish  this 
so-called  recurring  ulcer  is  serious  haemorrhage,  being 
repeated  every  year  or  two,  or  at  even  longer  intervals, 
oftentimes  at  fixed  epochs.  Lastly,  in  other  instances 
these  recurring  haemorrhages  are  due  to  multiple 
ulcers  quite  independent  of  each  other,  but  these  are 
exceptional. 

The  repetition  of  the  haemorrhage  therefore  implies, 
in  a  general  way,  the  notion  of  chronic  ulcer,  whether 
the  bleeding  be  simply  chronic  or  recurring.  For 
that  matter,  this  distinction  is  of  no  great  value.  For 
years  it  has  been  known  that  the  progress  of  chronic 
ulcer  often  proceeds  by  more  or  less  acute  outbreaks, 
and  that  these  outbreaks  may  occur  with  a  certain 
periodicity,  coinciding  with  a  season,  a  fixed  date  or 
an  anniversary.  The  influence  of  the  nervous  sys- 
tem, and  perhaps  the  endocrinic  glands,  is  not  with- 
out influence  on  these  particular  recurrences.  It  is 
natural  that  during  the  course  of  these  acute  attacks 
a  haemorrhage  is  more  prone  to  arise. 

Therefore,  if  exception  be  made  of  some  cases  in 
which  the  existence  of  multiple  ulcers  may  be 
accepted  with  some  degree  of  certainty  and  those 
exceptional  instances  which  Julich  maintains  heal 
and  completely  disappear  in  the  interval  between  the 
acute  outbursts,  it  can  be  said  that  repeated  serious 
haemorrhage  is  always  produced  by  chronic  ulcer. 
This  notion  is  not  devoid  of  interest  in  regard  to  the 
treatment.  Contrary  to  what  we  said  relating  to 
fulminating  acute  haemorrhage,  the  notion  of  ulcer 
is  here  foremost.  The  physician  is  no  longer  in  the 
presence  of  a  sudden  complication  which  places  the 


288  SURGICAL  TREATMENT 

patient's  life  in  jeopardy  in  the  space  of  a  few 
hours.  The  loss  of  blood  is  merely  a  sign  of  the 
gravity  of  the  affection  to  be  treated,  so  that  the 
complication  needs  less  consideration  than  the  lesion 
giving  rise  to  it.  The  treatment  and  indica- 
tions for  operation  are  clearly  different  in  each 
circumstance. 

The  indications  for  operation  are  here  infinitely 
easier  to  decide,  and  most  surgeons  maintain  that 
operation  is  necessary.  The  only  question  subject 
to  some  discussion  is  to  know  when  and  how  the 
operation  is  to  be  done.  The  reason  why  an  opera- 
tion is  invariably  indicated  in  these  cases  is  simple  in 
the  extreme.  We  have  said  that  repeated  haemor- 
rhage indicates,  if  not  always,  at  least  in  the  great 
majority  of  cases,  a  chronic  ulcer.  It  even  implies 
the  idea  of  a  particularly  stubborn  character.  Now 
what  can  medical  treatment  do  in  cases  of  chronic 
ulcer  ?  We  know  that  it  is  powerless,  that  it  is 
devoid  of  any  therapeutical  results.  On  the  other 
hand,  we  know  how  much  can  and  should  be  expected 
from  surgical  interference,  and  this  reason  alone 
should  make  one  accept  operation  as  the  only  logical 
conclusion.  And,  still  more,  the  appearance  of  such 
a  serious  complication  as  haemorrhage  clearly  demon- 
strates the  danger  of  instituting  a  treatment  of  long 
duration,  which  in  reality  gives  such  little  security. 
In  fact,  these  haemorrhages,  if  not  fatal  within  a 
short  space  of  time,  are  always  serious,  their  gravity 
usually  increasing  with  the  number  of  recurrences, 
and  more  than  one  case  is  known  in  which,  although 
not  disquieting  at  the  onset,  the  loss  of  blood  becomes 


ILEMORRHAGIC  ULCER  239 

progressively  serious  and  finally  may  result  in  death 
in  a  few  hours. 

Hence  this  complication  imparts  a  special  character 
to  the  ulcer,  but  in  the  case  under  consideration,  at 
least  at  the  onset,  the  haemorrhage  is  not  the  sole 
symptom  upon  which  attention  should  be  concen- 
trated, with  the  result  that  all  therapeutical  measures 
are  directed  to  it.  In  the  great  majority  of  cases 
these  haemorrhages,  especially  the  early  ones,  cease 
quite  readily  by  medical  treatment,  so  that  it  will  be 
rarely  a  question  of  urgent  surgical  measures.  It  is 
usually  only  when  the  patient  has  recovered  from  the 
loss  of  blood  that  the  question  of  operation  will  arise. 
For  this  reason  the  loss  of  blood  becomes  for  many 
observers  a  formal  indication  for  surgical  interference, 
even  among  those  who  are  disinclined  to  surgery — 
von  Leube,  for  example. 

But  when  should  the  surgical  act  be  resorted  to  ? 
This  is  somewhat  a  delicate  question,  and  opinion  is 
moot.  Some  believe  that  a  haemorrhage  occurs  in 
simple  peptic  ulcer,  and  although  the  loss  of  blood 
may  be  considerable,  it  will  cease  spontaneously, 
never  to  recur,  and  from  this  fact  they  consider 
operation  to  be  perfectly  useless.  They  prefer  to 
become  convinced  that  the  haemorrhage  has  assumed 
the  repeating  type,  and  await  a  second  warning 
before  seriously  considering  the  advisability  of 
interfering  surgically. 

Others,  on  the  contrary,  regard  serious  haemorrhage 
as  a  sign  of  chronicity  of  the  ulcer  and  also  the 
gravity  of  the  lesion,  maintaining  that  it  is  hazardous 
to  allow  the  patient  to  run  the  risk  of  a  second 


240  SURGICAL  TREATMENT 

haemorrhage,  and  prefer  to  operate  after  the  first  loss 
of  blood. 

This  divergence  of  opinion  is  principally  due  to  the 
idea  that  has  been  formed  of  the  dangers  inherent  to 
all  surgical  work.  For  some,  who  certainly  exag- 
gerate it,  the  danger  is  greater  than  that  offered 
by  a  second  haemorrhage,  which  possibly,  but  not 
certainly,  may  ensue.  For  others,  who  are  aware 
of  the  low  mortality  of  operations  done  in  satisfactory 
conditions,  the  operative  risk  is  less  considerable  than 
that  of  a  badly  armed  expectant  attitude. 

It  is  certain  that  it  would  be  pessimistical  to 
operate  on  all  cases  of  ulcer  which  have  given  rise  to 
serious  haemorrhage.  It  must  be  unhesitatingly 
admitted  that  in  many  instances  no  recurrence  takes 
place,  and  it  is  merely  a  symptom  of  an  acute  ulcer 
which  may  undergo  a  rapid  evolution  towards  a  final 
and  durable  cure  simply  by  proper  medical  treatment. 

But  how  can  simple  haemorrhage  be  differentiated 
from  recurring  haemorrhage  ?  The  characters  of  the 
haemorrhage  envisaged  alone  can  hardly  offer  any 
sure  data  in  this  regard.  Therefore  other  symptoms 
must  be  considered,  as  well  as  the  anamnesis,  the 
health  and  age  of  the  subject.  Unquestionably  a 
patient  with  a  serious  haemorrhage  will  be  running 
greater  risk  of  having  it  recur  if  he  has  suffered  for 
several  years  from  an  ulcer  in  activity  than  one  who 
has  never  presented  any  gastric  antecedents. 

There  is  also  greater  probability  of  repetition  of  a 
haemorrhage  when  this  occurs  in  the  age  of  full 
activity  than  in  a  young  girl  of  eighteen  or  twenty. 
In  fact,  in  young  people  generally  the  ulcer  has  an 


H^EMORRHAGIC  ULCER  241 

infinitely  more  rapid  evolution  and  has  less  tendency 
to  chronic  evolution  than  in  subjects  of  riper  years. 
In  them  a  haemorrhage  may  arise  and  even  be 
alarming,  but  will  not  recur,  as  the  ulcer  rapidly 
cicatrises.  But  this  question  can  never  be  governed 
by  fixed  rules  and  axioms,  which  are  only  pillows  for 
the  lazy.  Therefore  each  case  must  be  considered 
by  itself  before  coming  to  any  decision.  The  chroni- 
city  of  the  ulcer,  which  is  more  frequent  than 
generally  suspected,  should  be  given  special  attention. 
If  one  is  certain  that  the  loss  of  blood  comes  from  an 
acute  ulcer,  it  is  perfectly  proper  to  await  events 
before  deciding  on  operation.  If  medical  treatment 
results  in  recovery  in  a  few  weeks,  an  operation  can 
be  regarded  as  useless,  which  is,  in  fact,  usually  the 
case. 

If,  on  the  contrary,  haemorrhage  arises  in  a  man 
of  adult  age,  even  if  no  gastric  antecedents  are  noted, 
the  question  assumes  an  entirely  different  aspect. 
Even  should  an  amelioration  quickly  ensue,  a  com- 
plete recovery  is  doubtful,  and  the  development  of 
further  accidents  is  to  be  anticipated.  Therefore  it 
is  prudent  to  forestall  them  by  resorting  to  operation, 
which,  in  most  instances,  will  demonstrate  the 
presence  of  a  chronic  ulcer.  It  is  perfectly  useless, 
or  even  dangerous,  to  await  a  repetition  of  the 
haemorrhage  before  operating. 

As  soon  as  the  patient  has  overcome  the  effects  of 
the  bleeding  it  is  time  to  interfere  surgically,  and  by 
so  doing  he  will  be  spared  any  further  untoward 
complications.  It  is  with  a  purpose  that  we  only 
speak  of  the  probability,  and  not  the  certitude,  of 


S.T. 


242  SURGICAL  TREATMENT 

the  results  of  the  surgical  act,  because  any  one  with 
experience  in  gastric  surgery  is  only  too  well  aware 
that  the  results  are  not  always  brilliant  or  durable. 

There  are  haemorrhagic  ulcers  as  there  are  chronic 
ulcers  in  general ;  the  great  majority  are  recovered 
from  completely  by  operation,  and  it  is  only  a  small 
minority  that  do  not  obtain  any  relief.  As  to  the 
operative  mortality,  it  is  at  the  present  time  so  low 
when  the  operation  is  undertaken  in  favourable 
circumstances  in  a  patient  with  little  or  no  cachexia 
that  it  is  hardly  necessary  to  reckon  with  it. 

We  therefore  maintain  that  serious  repeated 
haemorrhage  is  a  formal  indication  for  an  operative 
act.  For  greater  security,  the  operation  should  be 
done  immediately  after  the  occurrence  of  the  first 
really  serious  loss  of  blood  when  there  is  the  slightest 
reason  to  suspect  that  the  ulcer  is  a  chronic  one. 
Alone,  the  haematemesis  in  young  subjects  arising 
from  an  ulcer  whose  acute  evolution  is  evident  is  in 
the  domain  of  medical  treatment.  It,  however, 
seems  to  us  more  prudent,  even  in  these  cases,  to  be 
ready  to  operate  when  the  ulcer  does  not  seem  to 
be  undergoing  cicatrisation  quickly  or  completely 
enough. 

It  should  not  be  forgotten  that,  speaking  in  a 
general  way,  the  rapidity  with  which  surgical  inter- 
ference is  resorted  to  is  one  of  the  best  guarantees  of 
its  success.  The  more  an  ulcer  is  allowed  to  assume 
a  chronic  evolution,  the  greater  will  be  the  chance  of 
recurrence. 

Choice  of  the  Procedure. — From  what  has  been 
said  it  is  clear  that  the  operation  is  directed  less 


ELEMORRHAGIC  ULCER  243 

against  the  haemorrhage  itself  than  for  dealing  with 
the  ulcer.  The  end  to  be  attained  in  the  majority 
of  these  cases  is  not  so  much  the  arrest  of  the  bleeding, 
which  unquestionably  is  dangerous,  but  rather  the 
prevention  of  the  recurrence  of  this  accident,  since 
the  operation  is  usually  undertaken  during  an  inter- 
val between  acute  attacks.  The  cure  of  the  ulcer  is 
generally  in  view,  thereby  forestalling  future  haemor- 
rhage. All  this  means  that  in  the  choice  of  the 
operative  procedure  the  surgeon  should  follow — at 
least  in  a  general  way — what  has  been  said  of  the 
various  operations  employed  in  cases  of  vulgar 
chronic  ulcer.  Therefore  it  is  useless  to  repeat  the 
discussion  of  the  advantages  and  disadvantages  of 
these  various  procedures,  a  discussion  which  we 
lengthily  exposed  in  a  preceding  chapter. 

Let  us  briefly  recall  that  we  believe  decidedly  in 
the  theoretical  and  practical  superiority  of  gastro- 
enterostomy  in  the  majority  of  cases.  Now  let  us  see 
if  in  the  particular  cases  under  consideration  gastro- 
enterostomy  maintains  that  superiority  claimed  for 
it  in  other  conditions.  This  procedure  is,  as  we  have 
said,  the  operation  of  choice  in  chronic  ulcer,  because 
it  is  devoid  of  any  great  risk  and  places  the  stomach 
in  the  most  favourable  physiological  conditions  for 
the  cure  of  the  ulcer.  But  it  requires  a  relatively 
long  time  to  bring  about  this  cure. 

Therefore  it  may  be  asked  whether  during  this  slow 
recovery  the  patient  is  not  continually  exposed  to 
the  occurrence  of  another  serious  loss  of  blood,  even 
sufficient  in  amount  to  be  fatal,  and  also  whether  or 
not  it  is  enough  to  place  the  stomach  in  improved 

B  2 


244  SUEGICAL  TREATMENT 

physiological  conditions  to  be  assured  that  further 
accidents  may  not  develop.  On  the  contrary,  might 
it  not  be  better,  as  far  as  greater  risks  are  concerned, 
to  prefer  a  more  serious  procedure,  but  one  that  gives 
a  surer  and  more  rapid  result  ?  These  are  questions 
that  clearly  cannot  be  solved  in  a  peremptory  way  and 
whose  answer  cannot  apply  to  each  particular  case. 

If  the  conclusions  of  the  various  writers  on  this 
subject  are  examined  based  on  a  considerable  num- 
ber of  cases  followed  for  a  time  sufficiently  long  to 
be  conclusive,  it  becomes  clear  that  the  majority  of 
writers  recognise  the  great  value  of  gastroenteros- 
tomy  in  repeated  serious  haBmorrhage.  A  complete 
list  of  these  writings  would  be  too  long  to  give,  so  that 
we  shall  only  quote  the  more  important  of  those 
advocating  gastroenterostomy,  after  which  reference 
will  be  made  to  the  partisans  of  resection.  We  would, 
in  the  first  place,  remark  that  the  opponents  of  gastro- 
enterostomy in  cases  of  haemorrhagic  ulcer  are  the 
same  men  that  we  have  already  mentioned  as  being 
opposed  to  this  procedure  in  simple  peptic  ulcer. 

Thus  Atkins,  Moullin,  Petersen  and  Czerny, 
Moynihan,  Korte,  Mayo-Bobson,  Eiselsberg,  Mikulicz 
and  Kreuzer  warmly  recommend  gastroenteros- 
tomy, which  they  believe  in  a  general  way  to  be  the 
surest  procedure,  the  one  that  shields  the  patient 
better  from  a  recurrence  without,  it  must  be  said, 
giving  complete  security. 

On  the  other  hand,  AH  Krogius,  Bakes,  Graf  and 
Eydigier  have  no  confidence  in  this  operation,  believ- 
ing that  resection  is  the  procedure  offering  greater 
chances  of  success. 


IkEMORRHAGIC  ULCER  245 

At  present  gastroenterostomy  is  gradually  losing 
the  favour  of  many  of  its  oldest  partisans,  their  faith 
now  being  pinned  on  resection,  because  the  early 
brilliant  results  of  the  former  procedure  were  followed 
by  recurrence  of  the  lesion. 

But  the  majority  of  the  cases  of  ulcer  are  too  dif- 
ferent from  each  other  to  be  all  suitable  for  the  same 
treatment.  If  most  surgeons  still  advise  gastro- 
enterostomy for  the  treatment  of  repeated  serious 
haemorrhage,  it  is  because  in  the  larger  number  of 
cases — even  when  the  operation  can  be  postponed 
until  the  patient  has  recovered  from  the  effects  of 
the  loss  of  blood — the  general  condition  of  these 
subjects  is  so  bad  that  it  is  a  contra-indication  for 
any  prolonged  or  laborious  interference,  such  as 
resection.  What  is  above  all  required  is  a  simple, 
rapid  and  mildly  traumatising  operation  which  will 
allow  the  patient  to  recuperate  his  health,  and  then, 
if  necessary,  a  second  operation  may  be  undertaken 
later  on  with  much  less  danger. 

Now  in  order  that  gastroenterostomy  shall  develop 
its  good  effects,  as  well  as  to  control  the  hemorrhages 
and  improve  the  general  health,  the  ulcer  must  be 
seated  in  the  pylorus  or  prepyloric  region.  In  fact, 
we  have  attempted  to  show  what  little  influence  it 
exercises  when  the  lesion  is  seated  in  the  fundus  and 
greater  curvature.  This  restriction  has  in  reality 
but  very  little  value,  because  the  great  majority  of 
haemorrhagic  ulcers  are  seated  in  such  a  part  of  the 
stomach  that,  from  their  very  position,  they  give  rise 
to  the  phenomena  of  stasis. 

The   irritation   of   the   ulcer   resulting   from   the 


246  SURGICAL  TREATMENT 

passage  of  food  plays  an  important  part  in  not  a  few 
instances ;  it  is  even  one  of  the  most  certain  causes  of 
the  ineffectiveness  of  gastroenterostomy,  as  has  been 
shown  in  two  of  von  Eiselsberg's  cases  as  well  as  in 
one  of  our  own.  In  these  three  cases  the  bleeding 
continued  in  spite  of  gastroenterostomy.  The  ulcers 
were  seated  in  the  pylorus,  while  the  stoma  placed 
above  the  lesion  seemed  to  sufficiently  divert  the 
gastric  contents,  so  that  the  requisite  rest  for  cicatrisa- 
tion to  take  place  appeared  to  have  been  obtained. 
But  in  all  three  it  was  necessary  to  do  an  exclusion  of 
the  pylorus  in  order  to  obtain  an  immediate  cessation 
of  the  haemorrhage.  This  clearly  proves  the  import- 
ance of  placing  the  ulcer  out  of  reach  of  the  perpetual 
irritation  resulting  from  the  contact  of  the  gastric 
contents  and  the  peristaltic  movements  of  the  viscus. 

On  the  contrary,  resection  in  these  cases,  even  the 
simplest,  like  that,  for  example,  where  no  adhesions 
exist,  is  invariably  a  serious  undertaking,  which  from 
its  duration,  and  the  manipulations  and  division  of 
the  peritoneal  ligaments  that  it  necessitates,  requires 
an  amount  of  resistance  that  most  subjects  are  far 
from  presenting. 

When  the  ulcer  is  seated  near  the  pylorus,  when  the 
haemorrhage  is  accompanied  by  signs  of  stenosis, 
gastroenterostomy  is  the  ideal  operation,  which,  with 
a  mortality  reduced  to  the  minimum,  gives  the 
maximum  of  ultimately  successful  results.  When  the 
ulcer  is  seated  on  the  greater  curvature  or  anterior 
wall,  which  is  certainly  exceptional,  simple  excision 
of  the  lesion,  with  suture  of  the  wound,  can  be  done. 
In  these  particular  circumstances  the  technique  is 


ILEMORRHAGIC  ULCER  247 

neither  difficult  nor  long  to  carry  out,  operative 
trauma  is  slight,  and  a  subject  even  in  poor  general 
condition  is  able  to  withstand  it  quite  as  well  as  a 
gastroenterostomy. 

Sometimes,  unfortunately,  adhesions  render  the 
operation  difficult,  and  may  even  be  so  dense  as  to 
become  a  real  contra-indication  for  this  procedure. 
Consequently  there  are  ulcers  that  can  hardly  be 
dealt  with  by  either  gastroenterostomy  or  resection  ; 
nevertheless  the  bleeding  cannot  be  allowed  to  con- 
tinue and  be  a  perpetual  source  of  danger. 

It  is  in  these  circumstances  that  the  other  pro- 
cedures we  have  studied  in  the  preceding  chapter  may 
render  unquestionable  service,  but  we  would  at  once 
add  that  these  will  always  be  exceptional.  Therefore 
infolding,  curettage  and  cauterisation,  and,  lastly, 
ligature  of  the  vessels  may  be  considered.  These 
procedures,  which  only  deal  directly  with  the  haemor- 
rhage, and  not  with  the  lesion,  and  in  fact  are  even 
nefarious  in  regard  to  the  ulcer  itself,  as  vascular 
ligature,  for  example,  are  only  incomplete  and  merely 
give  temporary  results.  They  are,  in  fact,  rarely 
employed.  Most  of  them  are  simple  and  rapid  when 
the  indications  dictated  by  the  special  circumstances 
of  each  case  lend  themselves  to  them. 

Finally,  jejunostomy  remains  to  be  considered, 
although  in  the  cases  under  consideration  it  does  not 
offer  any  particular  indication.  The  special  indica- 
tions are  the  same  as  those  which  have  been  reviewed 
in  the  case  of  fulminating  haemorrhage,  and  it  only 
needs  to  be  recalled  that  this  operation  is  an  excellent 
means  for  assuring  as  complete  a  rest  as  is  possible  to 


248  SURGICAL  TREATMENT 

the  stomach  while  the  patient  can  continue  to  take 
food.  Therefore  when  adhesions  are  too  extensive, 
when  a  real  peri  gas  trie  mass  prevents  the  stomach 
from  being  easily  manipulated,  jejunostomy  will 
render  excellent  service  by  allowing  the  general  con- 
dition of  these  subjects  to  be  restored  in  those  cases 
where  prolonged  inanition  has  reduced  them  to  the 
state  of  skeletons. 

From  the  rest  procured  by  it  the  procedure  may 
bring  about  a  cure  of  the  ulcer,  as  von  Eiselsberg  and 
Maydl  have  pointed  out.  But  most  usually  it  allows 
the  surgeon  to  await  the  proper  time  for  a  more  direct 
action,  which  will  result  in  the  permanent  cure  of  the 
ulcer  by  controlling  the  acute  attacks  and  causing 
absorption  of  the  perigastric  callous  masses  to  take 
place. 

Chronic  Latent  Haemorrhage. — In  chronic  latent 
bleeding  the  dramatic  phenomena  of  fulminating 
haemorrhage  or  those  of  repeated  serious  hemorrhage 
are  absent.  Quite  on  the  contrary,  the  loss  of  blood 
is  often  overlooked  if  not  searched  for  with  great  care. 
These  chronic  haemorrhages  are,  in  fact,  so  insignifi- 
cant at  first  sight  that  they  are  even  unnoticed  by  the 
patient,  so  that  at  the  onset  they  seem  to  be  almost 
devoid  of  any  importance.  It  is  only  little  by  little,  by 
their  repetition  and  frequency,  that  they  finally  react 
on  the  general  health,  producing  a  state  of  weakness 
whose  true  cause  is  often  unsuspected.  But  when  a 
severer  haemorrhage  occurs  and  is  revealed  by  an 
occult  haematemesis  the  attention  of  the  physician  is 
directed  to  the  real  etiological  factor  of  the  anaemia. 

This  shows   the  great  importance  of  making  a 


ILEMORBHAGIC  ULCER  249 

systematical  search  with  simple  laboratory  methods 
in  order  to  detect  the  loss  of  blood. 

This  type  of  gastrorrhagia  is  practically  only 
encountered  in  chronic  ulcers  with  a  slow  evolution, 
often  insidious  and  torpid.  Usually  it  occurs  in 
patients  in  the  full  bloom  of  life,  rarely  in  young  sub- 
jects, and  if  to  this  fact,  cachexia  and  weakness  the 
sallow  yellow  tint  of  the  integuments  be  added,  it  is 
readily  conceived  that  the  first  diagnosis  coming  to 
the  mind  will  be  that  of  malignant  disease. 

In  fact,  small  repeated  loss  of  blood  is  one  of  the 
well-known  symptoms  of  gastric  carcinoma,  so  small 
in  amount  that  it  is  overlooked,  absolutely  analogous 
to  the  continued  oozing  of  a  wound  undergoing  the 
process  of  granulation  when  it  is  irritated.  Therefore 
when,  already  suspecting  a  malignant  process  on 
account  of  the  progress  of  the  affection  and  its 
reaction  on  the  general  health,  search  for  traces  of 
blood  in  the  faeces  is  made  with  positive  findings,  the 
diagnosis  of  cancer  is  probable,  and  many  clinicians 
would  not  hesitate  to  make  it. 

However,  a  few  examinations  only,  especially  if 
they  are  separated  by  somewhat  long  intervals,  are 
not  enough  to  make  a  certain  diagnosis.  It  is  well 
known  how  readily  malignant  ulcers  bleed  in  general. 
Chronic  gastric  ulcers  do  not  give  rise  to  such  con- 
stant loss  of  blood.  More  severe  when  it  does  occur, 
the  haemorrhage  always  ceases  for  a  certain  lapse  of 
time,  at  least  in  most  instances,  so  that,  given  a 
certain  number  of  examinations,  there  will  always  be 
some  which  will  remain  negative. 

Hence  in  cases  of  true  chronic  haemorrhage  it  is 


250  SUEGICAL  TREATMENT 

not  enough  to  make  a  few  examinations  at  regular 
intervals,  but  preferably  to  repeat  them  daily  for  a 
certain  lapse  of  time.  Should  they  prove  to  be  con- 
stantly positive,  there  will  be  good  ground  for  sup- 
posing that  cancer  exists.  If,  on  the  contrary,  a 
certain  intermittence  in  the  appearance  of  the  blood 
is  noted,  the  diagnosis  of  chronic  ulcer  may  be  made 
with  a  good  degree  of  probability. 

This  distinction  is  necessary  to  make  because,  in 
spite  of  the  fact  that  in  each  case  an  operation  is 
imperative,  the  diagnosis  will  considerably  influence 
the  choice  of  the  procedure  to  be  employed,  all  the 
more  so  because  malignant  transformation  of  a 
chronic  ulcer  must  never  be  lost  sight  of,  and  this 
change  is  not  always  recognised  anatomically. 

Chronic  haemorrhage  is  one  of  the  least  moot 
indications  of  operative  treatment,  since  both 
physicians  and  surgeons  recognise  the  fact  that  it  is 
perfectly  illusive  to  resort  to  medical  treatment. 
Chronic  ulcer  is  rebellious  to  internal  therapeutical 
measures ;  it  resists  everything ;  and  during  this  time 
the  patient,  worn  out  not  only  from  dyspeptic  dis- 
turbances, but  also  from  the  anaemia  resulting  from 
the  continual  loss  of  blood,  notices  that  his  strength 
declines  day  by  day,  strength  that  is  so  essential  for 
the  ordeal  of  the  operative  act.  Hence  not  only  are 
the  indications  clear  and  precise  for  operation,  but 
this  should  be  done  as  soon  as  possible,  as  any  delay 
will  be  baneful  when  not  disastrous. 

Choice  of  the  Procedure. — Since  the  loss  of  blood  in 
these  cases  is  not  disquieting,  and  does  not  necessitate 
the  energetic  measures  of  fulminating  haemorrhage, 


ILEMORRHAGIC  ULCER  251 

all  special  procedures  can  be  eliminated  at  once,  such 
as  ligature  of  a  vessel,  curettage  and  cauterisation. 
In  the  majority  of  cases  the  plan  of  operation  will  be 
to  deal  directly  with  the  ulcer  in  order  to  effect  its 
cure,  following  in  this  regard  the  indications  we  have 
enumerated  when  speaking  of  the  treatment  of 
simple  peptic  ulcer. 

The  procedures  most  usually  employed  are  : — 

Gastroenterostomy ; 

Resection  of  the  stomach  ; 

Combined  gastroenterostomy  and  resection  ; 

Infolding  of  the  ulcer ; 

and  very  infrequently,  although  this  is  a  great  mis- 
take, gastroenterostomy  combined  with  exclusion  of 
the  pylorus. 

The  same  advantages  and  disadvantages  inherent 
to  resection  exist  here  as  those  previously  studied, 
this  operation,  however,  presents  with  this  indication 
certain  unquestionable  advantages  which  should 
make  it  preferred  to  other  procedures. 

The  first  of  these  advantages  is  derived  from  the 
fact  that  these  chronic  losses  of  blood  have  in  all 
probability  led  to  the  suspicion  of  carcinoma  or 
neoplastic  transformation  of  the  ulcer.  Therefore, 
when  direct  examination  of  the  stomach  is  incapable 
of  eliminating  the  diagnosis  of  malignant  degenera- 
tion, preference  should  be  given,  should  circum- 
stances permit,  to  that  procedure  which  will  relieve  all 
doubt,  and  alone  offers  any  hope  of  a  permanent  cure. 
The  second,  less  important,  is  that  resection  will 
at  once  do  away  with  the  haemorrhages  and  permit 
of  an  infinitely  quicker  amelioration  of  the  general 


OL 


252  SURGICAL  TREATMENT 

health.  On  the  other  hand,  the  disadvantages 
remain  the  same,  especially  the  greater  risk  incurred 
by  this  procedure.  It  should  be  remembered  that 
the  general  health  of  these  subjects  having  chronic 
haemorrhage  which  dates  back  a  long  time  is  hardly 
what  can  be  called  brilliant,  and  usually  will  not 
admit  of  a  prolonged  surgical  act. 

As  we  have  said,  gastroenterostomy  is  the  operation 
to  which  we  accord  the  greatest  influence  in  the  cure 
of  ulcer,  especially  when  this  lesion  is  accompanied 
by  a  pyloric  stenosis.  To  accelerate  the  effect  of 
gastroenterostomy  infolding  of  the  ulcer  may  be  done 
should  circumstances  permit,  as  it  will  completely 
control  the  loss  of  blood. 

Lastly,  one  other  complementary  operation  to 
gastroenterostomy  should  be  referred  to,  namely, 
exclusion  of  the  pylorus  or  even  the  entire  prepyloric 
region.  This  procedure  should,  we  believe,  always 
accompany  gastroenterostomy,  except  in  complete 
and  permanent  stenosis  of  the  pylorus.  And  still 
more  when  the  ulcer,  the  source  of  the  bleeding,  is  at 
the  pylorus  or  in  the  prepyloric  region,  exclusion  will 
give  it  complete  rest.  It  can,  therefore,  cicatrise 
with  greater  ease,  and,  above  all  else,  it  will  no  longer 
have  any  tendency  to  bleed.  At  the  same  time,  since 
the  gastric  contents  can  no  longer  follow  their  normal 
transit,  they  are  compelled  to  pass  through  the  stoma, 
which  will  assure  the  latter  both  regular  and  per- 
manent functions. 

As  to  jejunostomy,  we  fail  to  see  that  it  offers  any 
special  indications  in  the  cases  under  consideration. 
As  in  repeated  serious  haemorrhage,  it  may  render 


ILEMORRHAGIC  ULCER  258 

service  when  the  stomach  is  surrounded  by  adhesions 
resulting  from  a  perigastritis  making  access  to  it  im- 
possible, or  when  the  state  of  the  subject  is  so  bad 
that  sufficient  food  must  be  given  at  all  costs  with, 
at  the  same  time,  complete  rest  of  the  stomach.  But 
these  cases  are  extremely  rare  in  practice,  and  very 
few  surgeons  will  be  driven  to  this  procedure.  It  is, 
however,  well  to  mention  this  operation,  which,  in 
the  circumstances  just  described,  will  unquestionably 
render  great  service. 

As  a  brief  summary  to  what  has  been  said,  we 
would  say,  firstly,  that  chronic  or  latent  haemor- 
rhages, symptoms  of  chronic  ulcer,  and  therefore 
rebellious  to  medical  treatment,  are  an  absolute 
indication  for  operative  interference  ; 

Secondly,  that  such  haemorrhages  should  invariably 
raise  the  suspicion  of  gastric  carcinoma  or  malignant 
transformation  of  an  ulcer,  suspicion  which  can  only 
be  removed  with  some  degree  of  probability  when 
methodical  examination  of  the  stools  shall  show  that 
the  loss  of  blood  is  intermittent  and  irregular,  with 
long  periods  of  remission  ; 

Thirdly,  that  the  treatment  of  choice,  given  this 
suspicion  of  malignancy,  should  be  resection  ; 

Fourthly,  that  when  the  patient's  general  health 
or  anatomical  circumstances  contra-indicate  this 
procedure  gastroenterostomy  will  give  excellent 
results,  although,  perhaps,  less  rapid  ; 

Fifthly,  that  in  order  that  this  operation  shall  have 
a  more  active  and  at  the  same  time  a  more  durable 
action  it  should  invariably  be  completed  by  exclusion 
of  the  pylorus. 


CHAPTER  IX 

PAINFUL   GASTRIC    ULCER 

IT  is  generally  admitted  that  pain  is  one  of  the 
chief  symptoms  of  ulcer  of  the  stomach ;  hence  it 
may  appear  rather  useless  to  give  it  a  place  apart  in 
respect  to  other  ulcers  presenting  this  symptom.  We 
would,  however,  at  once  declare  that,  contrary  to  a 
very  prevalent  opinion,  gastric  ulcer  is  not  in  itself 
painful,  and  only  becomes  so  in  certain  circumstances. 

Discussion  is  still  rife  in  regard  to  the  semeiological 
value  and  pathogenesis  of  gastric  pain,  and  the 
subject  is  even  now  moot.  For  many  writers  the 
origin  of  pain  in  ulcer  is  not  any  more  denned  than 
that  of  other  gastrological  phenomena.  It  must  be 
said  that  those  who  have  participated  in  the  dis- 
putes on  gastric  pain  appear  to  still  ignore  the 
researches  carried  out  on  the  sensibility  of  the 
stomach  in  the  normal  state,  as  well  as  that  of  the 
abdominal  viscera  in  general. 

Lennander  was  one  of  the  first  to  recognise  that 
the  sensibility  of  these  organs  is  almost  nil.  For 
that  matter,  it  is  easy  to  satisfy  oneself  in  this  respect 
when  performing  a  gastric  operation  under  infiltra- 
tion anaesthesia.  The  opening  of  the  gut  after 
colostomy,  division  and  cauterisation  of  the  intestine 
or  the  ligature  of  the  vessels  of  the  abdominal  viscera 
are  devoid  of  painful  phenomena.  These  examples 


PAINFUL  GASTRIC  ULCER  255 

are  the  most  generally  known,  but  the  same  cannot 
be  said  of  the  stomach.  We  have  always  noted  in 
gastrotomies  that  we  have  done  under  infiltration 
anaesthesia  that  only  handling  of  the  parietal  peri- 
toneum is  painful,  and  that  the  surgical  act  on  the 
stomach  is  never  complained  of  by  the  patient. 
There  is  only  one  thing  to  be  careful  about,  and  that 
is  to  draw  out  the  stomach  with  extreme  gentleness. 

All  this  goes  to  show  that  the  walls  of  the  stomach 
are  completely  deprived  of  sensibility  ;  they  abso- 
lutely do  not  react  to  mechanical  excitation.  On  the 
contrary,  traction  on  the  organ  produces  very  sharp 
pain.  This  is  quite  in  accord  with  Lennander's  experi- 
ments, which  proved  that,  although  the  abdominal 
viscera  are  themselves  insensible,  the  mesos  depend- 
ing upon  the  parietal  peritoneum  are  endowed  with 
exquisite  sensibility. 

Many  writers,  although  in  accord  on  this  point, 
affirm  that  the  gastric  mucosa  is  sensitive  to  heat. 
We  have  been  able  to  demonstrate  that  this  is  not 
so.  Cauterisation  of  the  gastric  mucosa  and  stomach 
wall  gives  rise  to  no  pain.  The  mucous  membrane 
of  the  stomach  does  not  perceive  thermic  excitations, 
and  the  burning  sensation  that  is  felt  when  a  hot 
fluid  is  ingested  is  to  be  explained  by  transmission  of 
the  heat  to  the  parietal  peritoneum  of  the  anterior 
abdominal  wall.  This  likewise  applies  to  pain 
arising  when  the  organ  is  distended.  Thus,  if  a 
normal  stomach  is  blown  up,  a  time  comes  when 
sharp  pain  is  experienced.  We  explain  this  by 
stretching  of  the  peritoneal  gastric  ligaments  resulting 
from  distension  of  the  stomach,  and  not  from  sensi- 


256  SURGICAL  TREATMENT 

bility  of  the  organ  itself.  Consequently,  according 
to  our  experience,  we  maintain  that  the  stomach 
wall  is  perfectly  insensitive.  On  the  other  hand,  the 
gastric  ligaments  emanating  from  the  parietal  peri- 
toneum are  endowed  with  an  exquisite  sensibility, 
which  may  be  the  origin  of  violent  pain. 

Great  importance  has  been  attached,  and  not 
without  reason,  to  the  neuropathic  state  of  the 
subject  in  the  production  of  gastric  pain.  The 
principal  argument  of  the  partisans  of  this  explana- 
tion of  gastralgia  is  the  fact  that  patients  afflicted 
by  neuropathic  gastralgia  perceive  a  pain  on  pressure 
over  the  epigastric  point.  Now  it  is  recognised  that 
this  point — seated  a  little  to  the  right  of  the  mid-line, 
half-way  between  the  tip  of  the  sternum  and  umbilicus 
— does  not  correspond  with  the  seat  of  the  lesion  or  to 
the  pylorus,  as  was  supposed,  but  in  reality  with  the 
solar  plexus.  This  point  is  clearly  the  centre  of 
spontaneous  and  provoked  pain  in  the  great  majority 
of  gastralgias,  but  is  particularly  sensitive  in  neuro- 
pathic individuals.  Hence  the  pain  complained  of 
by  these  subjects  is  explained  by  hyperexcitation  of 
the  splanchnic  nerves,  and  not  by  an  irritation  or 
even  an  erosion  of  the  inflamed  mucous  membrane. 

That  this  view  is  justified  in  a  large  number  of 
cases  we  do  not  wish  to  deny,  but  it  appears  to  us 
very  exaggerated  to  admit  that  the  gastric  pain  is 
a  certain,  almost  pathognomonic,  sign  of  a  neuro- 
pathy, as  Lyon  would  have  us  believe. 

The  ulcer  frequently  gives  rise  to  spontaneous 
paroxysmal  pain  and  sensitiveness  to  pressure  over 
the  epigastric  point,  although  a  neuropathic  state 


PAINFUL  GASTRIC  ULCER     257 

need  not  necessarily  coexist  with  the  organic  lesion. 
In  reality  painful  ulcer  and  neuropathy  are  frequently 
associated.  It  will  often  be  somewhat  difficult  to 
ascertain  just  how  much  is  due  to  the  nervous  state 
and  how  much  to  the  ulcer  itself.  The  diagnosis  is, 
nevertheless,  important,  because  the  treatment  of 
these  two  affections  is  very  different.  Many,  relying 
on  our  too  modern  theories,  find  it  easier  to  consider 
both  affections  as  purely  nervous,  and  treat  them  as 
such. 

By  means  of  oddly  extravagant  regimen  and  skilful 
psychotherapy  they  will  in  the  end  decrease  the 
pain.  A  very  evident,  but  deceitful,  improvement 
in  the  patient's  condition  may  even  result,  because 
as  soon  as  the  subject  is  left  to  his  own  devices,  and 
treatment  by  suggestion  is  ceased,  the  gastralgia  due 
to  the  always  active  ulcer  will  return  with  increased 
intensity.  This  practice  is  really  very  dangerous, 
because  it  results  in  the  loss  of  much  valuable  time. 
Not  only  does  the  lesion  progress,  assuming  a  more 
and  more  chronic  aspect,  therefore  reacting  still 
more  profoundly  on  the  functions  of  the  stomach, 
during  these  so-called  marvellous  cures,  but  at  each 
relapse — and  they  are  numerous — the  patient  loses 
courage.  He  loses  confidence  more  and  more,  while 
at  the  same  time  his  energy  leaves  him,  not  only 
moral  energy,  but  likewise  the  energy  of  his  vital 
functions  in  general  and  the  digestive  energy  in 
particular.  When  at  last  he  perceives  that  the 
neuropathic  state  is  not  the  only  cause  of  his  dis- 
comfort, and  that  it  is  combined  with  a  serious 
anatomical  lesion  that  should  have  been  dealt  with 


258  SUEGICAL  TEEATMENT 

urgently,  it  will  often  be  too  late.  Surgical  treat- 
ment gives  infinitely  less  brilliant  results  in  cases 
where  the  nervous  element  is  very  greatly  involved. 
The  prognosis  quoad  fonctionem  is  to  be  much  more 
reserved  in  a  neuropathic  subject  than  in  a  purely 
organic  one,  and  all  surgeons  are  of  this  opinion. 

Consequently  before  at  once  accepting  the  neuro- 
pathic origin  of  the  pain,  even  when  a  nervous  state 
is  very  manifest,  the  process  should  invariably  be 
regarded  as  an  organic  affection,  ulcer  being  especially 
searched  for,  until  proved  to  be  the  contrary.  Eobin 
very  properly  advised  recourse  to  Weber's  reaction 
systematically  carried  out — search  for  blood  in  the 
stools — in  order  to  detect  an  ulcer  whose  symptoms 
are  concealed  by  a  too  evident  neuropathic  state. 

If  after  serious  observation  and  repeated  examina- 
tion of  the  fseces  no  evidence  of  ulcer  is  made  out, 
one  may — but  at  this  time  only — accord  the  capital 
importance  that  one  is  much  too  tempted  to  attribute 
at  once  to  the  patient's  neurosism.  We  do  not  wish 
to  imply  that  the  nervous  state  is  to  be  disdained  ; 
far  from  it.  On  the  contrary,  it  should  be  dealt 
with  seriously  and  treated  with  every  necessary 
energy ;  but  this  can  be  done  simultaneously  with 
the  treatment  of  the  organic  gastric  lesion. 

The  pain  observed  during  the  evolution  of  simple 
peptic  ulcer  can  usually  be  quickly  controlled  by 
judicious  treatment.  When  the  stomach  has  been 
put  to  rest,  when  a  proper  diet  avoids  excessive 
excitation  of  the  gastric  mucosa,  the  pain  will  rapidly 
subside,  and  often  disappear  completely  with  time. 
The  disappearance  of  the  pain  goes  hand  in  hand 


PAINFUL  GASTRIC  ULCER  259 

with  recovery  and  cicatrisation,  which  is  the  general 
rule  in  the  evolution  of  the  ulcer. 

There  are,  however,  cases  in  which  the  pain  and 
other  symptoms  disappear,  thus  leading  one  to 
suppose  that  the  treatment  is  effective  ;  but  upon 
the  slightest  irregularity  in  diet  or  the  least  fatigue 
the  pain  promptly  returns,  and  prevents  the  indi- 
vidual from  attending  to  his  daily  affairs.  These 
cases  where  medical  treatment  is  powerless  are 
those  that  interest  us  more  especially  as  surgeons. 

How  are  these  rebellious  pains,  persisting  after 
the  other  symptoms  of  ulcer  have  disappeared,  to  be 
explained  ?  From  what  we  have  said  of  gastric 
sensibility,  a  simple  peptic  ulcer  can  hardly  be 
looked  upon  as  the  origin.  The  pain  is  generally 
different  from  that  occurring,  so  to  speak,  normally 
at  the  onset  of  an  ulcer.  For  example,  it  is  not 
related  to  the  nature  of  the  food  ingested  or  to  the 
degree  of  acidity  of  the  gastric  juice,  but  depends 
more  upon  the  amount  of  food  taken,  the  overloading 
of  the  stomach,  and  the  consequent  dragging  on  the 
peritoneal  ligaments. 

It  is  far  more  just  to  admit  that  the  cause  of  the 
pain  is  an  irritation  of  the  sensitive  portion  of  the 
abdominal  serosa,  namely,  the  gastric  peritoneal 
ligaments.  It  is  for  this  reason  that  Robin  explains 
the  pain  as  being  due  to  adhesive  perigastritis,  whose 
painful  phenomena  differ  from  those  of  ulcer  ;  they 
are  aggravated  by  walking  and  standing ;  vomiting 
relieves  them. 

The  pain  complained  of  by  these  patients  is  of  a 
different  order  and  type.  Most  frequently  it  is  the 

s  2 


260  SURGICAL  TREATMENT 

pain  usually  termed  tardy  pain,  occurring  three  to 
four  hours  after  meals  :  the  other  kind,  which  is  less 
common,  is  early  pain  ;  that  is  to  say,  coming  on 
directly  after  the  ingestion  of  food.  Now,  if  peri- 
gastritis  be  looked  upon  as  the  usual  cause  of  the 
tenacious  pain  of  ulcer,  it  can  be  readily  understood 
why  tardy  pain  is  much  more  frequent  than  early 
pain. 

Any  question  of  stenosis  being  laid  aside,  the  late 
pain  appears  at  the  time  when  the  pylorus,  prepyloric 
region  and  the  first  portion  of  the  duodenum,  being 
mobilised  by  the  contractions  set  up  by  the  passage 
of  the  gastric  contents,  exercise  traction  on  the 
adhesions  which  surround  them.  The  early  pain  is 
due  to  the  dragging  set  up  by  the  peristaltic  move- 
ments of  the  cardiac  region  and  fundus  of  the 
stomach.  Now  we  have  attempted  to  show  how 
much  more  infrequent  are  ulcers  in  this  region, 
especially  the  more  serious  types,  than  those  seated 
in  the  immediate  neighbourhood  of  the  pylorus. 

Therefore  if  we  admit  that  early  as  well  as  late 
pain  is  caused  by  adhesions — the  consequence  of 
an  irritation  of  the  peritoneum  in  the  area  of  the 
ulcer — it  must  be  recognised  that  the  tenacious 
pain,  which  resists  all  properly  directed  and  prolonged 
medical  treatment,  is  a  sure  sign  of  the  gravity  of 
the  ulcer. 

To  produce  the  adhesions  the  ulcer  can  only  be 
of  the  chronic  variety,  which  in  itself  is  rebellious 
to  medical  treatment  in  the  majority  of  cases.  And 
what  is  more,  even  if  medical  treatment  should 
exercise  a  salutary  influence,  it  will  clearly  have  no 


PAINFUL  GASTRIC  ULCER  261 

effect  on  the  adhesions.  Unquestionably  if  the 
latter  are  fresh  and  have  not  undergone  organisation, 
the  causal  lesion  having  disappeared,  they  may 
undergo  absorption.  But  such  a  fortunate  event 
can  hardly  be  looked  for. 

In  the  vast  majority  of  cases,  especially  when  the 
pain  has  been  present  for  some  time,  there  is  only  one 
remedy,  namely,  gastrolysis,  the  surgical  removal 
of  the  adhesions,  oftentimes  very  few  in  number 
and  size,  which  are  the  factors  of  the  gastralgic 
phenomena. 

Nevertheless,  as  we  said  when  speaking  of  simple 
peptic  ulcer  in  activity,  resort  to  the  knife  should 
not  be  had  as  soon  as  an  ulcer  is  suspected  whose 
painful  phenomena  are  due  to  adhesions.  Although 
it  may  be  dangerous  to  delay  operative  treatment  too 
long,  medical  treatment  should  always  be  put  to  the 
test  at  first.  Even  if  it  has  no  direct  effect,  it  gives 
an  opportunity  of  more  complete  observation  of  the 
patient,  and  hence  a  correct  diagnosis  may  be 
reached,  a  matter  always  delicate.  One  may  also 
profit  by  this  time  to  treat,  if  necessary,  the  nervous 
state  of  the  individual,  which  is  frequently  com- 
promised. It  is  quite  impossible  to  estimate  how 
long  medical  treatment  should  be  continued,  as  the 
circumstances  in  each  case  differ  so  widely  ;  the 
conditions  special  to  each  will  permit  a  longer  essay 
with  drugs,  or,  on  the  contrary,  will  make  decision 
early  in  favour  of  operation,  just  as  is  the  case  in 
simple  ulcer  or  incomplete  stenosis. 

A  subject  who  is  not  compelled  to  give  himself 
up  to  physical  work,  one  who  can  be  seriously 


262  SURGICAL  TREATMENT 

treated  and  for  whom  giving  up  his  occupations 
will  not  be  a  cause  for  worry — such  a  patient  can 
expect  more  from  medical  treatment,  and  can 
continue  it  longer. 

It  is  quite  a  different  matter  when  contrary 
circumstances  exist.  Here  medical  treatment  cannot 
exercise  so  complete  an  action,  because  the  worries 
of  all  kinds,  the  anxieties  of  everyday  life,  have  a 
very  distinct  repercussion  on  the  evolution  of  the 
ulcer.  It  is  just  these  patients  who  readily  become 
neuropathic,  neurasthenics  with  an  anatomical  sub- 
stratum, we  admit,  but  nevertheless  neurasthenics. 

When  the  neurosism  of  the  patient  does  not 
quickly  subside  during  medical  treatment,  it  is 
dangerous  to  insist  upon  its  continuation.  The 
slight  improvement  that  may  result  is  often  nefarious 
in  that  it  hides  the  true  condition  of  the  patient.  In 
spite  of  this  apparent  amelioration,  the  neuropathic 
state  of  the  patient  remains  stationary,  a  fact  that 
will  be  soon  perceived  as  soon  as  the  subject  is  left 
to  himself. 

Now  we  have  already  said  that  it  is  a  very 
dangerous  affair  to  allow  this  neurosism  to  become 
installed  in  subjects  for  future  operation  and  how 
greatly  the  operative  results  suffer  from  it.  Many 
perfectly  justifiable  operations,  carried  out  with  all 
necessary  exactitude,  have  remained  without  effect, 
and  very  frequently  the  cause  of  these  failures  should 
not  be  looked  for  elsewhere  than  in  the  state  of 
nervous  depression  into  which  these  patients  have 
fallen. 

Operative   treatment   gives   excellent   results   in 


PAINFUL  GASTRIC  ULCER  263 

general.  According  to  the  procedure  adopted,  as 
well  as  the  characters  of  the  anatomical  lesion, 
recovery  will  ensue  more  or  less  promptly,  more  or 
less  completely,  but  an  evident  amelioration  is  the 
rule. 

It  is  impossible  to  form  an  exact  idea  of  the  results 
obtained  in  cases  of  painful  ulcer  without  the 
phenomena  of  stasis.  In  most  writings  on  the  subject 
this  distinction  is  not  made,  while  the  details  given 
of  the  cases  are  often  insufficient  to  establish  a 
clear  classification. 

We  are  consequently  obliged  to  consider  painful 
ulcer  from  a  general  standpoint,  all  the  more  so 
because  this  chapter  of  gastric  pathology  has  not 
been  sufficiently  studied,  and  statistics,  to  which  we 
attribute  only  a  secondary  importance  it  is  true, 
are  wanting.  Nevertheless  by  consulting  the  various 
cases  scattered  throughout  the  literature  we  come  to 
the  conclusion  that,  in  the  vast  majority  of  cases,  a 
permanent  complete  recovery  is  obtained.  In  some 
the  cure  was  incomplete,  the  patients  still  complaining 
of  some  pain,  but  which  was  not  enough  to  prevent 
them  from  attending  to  their  daily  occupations  ;  in 
others,  less  numerous,  the  subjects,  after  having  en- 
joyed an  evident  improvement,  were  again  afflicted 
by  the  pain ;  finally,  others — and  these  were  in  an 
infinite  minority — continued  to  suffer  from  gastralgia 
quite  as  severely  as  before  the  operation. 

The  various  proportions  in  this  classification  of 
the  results  of  operative  treatment  may  be  compared 
with  those  given  in  the  case  of  operative  interference 
in  simple  peptic  ulcer. 


CHAPTER  X 

PERFORATED  GASTRIC  ULCER 

IT  is  to  this  complication  that  the  majority  of 
deaths  from  gastric  ulcer  are  due.  It  occurs  with 
fair  frequency,  especially  in  males  in  the  prime  of  life. 
We  have  already  shown  how  often  an  ulcer  assumes 
a  chronic  form  in  these  subjects,  as  well  as  a  peculiarly 
rebellious  character.  It  is  not,  therefore,  astonish- 
ing that  these  ulcers  have  a  greater  tendency  to 
perforate  than  those  undergoing  a  more  dramatic 
evolution,  but  more  rapid  and  less  dangerous,  in 
young  subjects. 

Perforation  is  frequently  the  first  clinical  evidence 
of  a  latent  ulcer.  Examination  at  operation,  and  at 
autopsy  unfortunately  only  too  often,  will  never- 
theless show  that  the  lesion  has  been  in  progress 
for  already  a  considerable  time.  By  carefully 
examining  the  patient's  antecedents  one  will,  in  most 
cases,  discover  gastric  symptoms  which  would  have 
given  rise  to  the  detection  of  the  ulcer.  The  lesion 
often  is  latent  only  because  it  does  not  greatly 
inconvenience  the  patient,  who,  therefore,  does  not 
attach  much  importance  to  the  gastric  symptoms, 
preferring  to  lead  his  ordinary  life  rather  than  to 
consult  a  physician,  who  would  subject  him  to  a 
diet  little  suited  to  his  gastronomic  tastes,  which  are 
usually  fairly  well  developed. 

Generally   speaking,   however,   even   during   the 


PERFORATED   GASTRIC  ULCER       265 

evolution  of  a  chronic  ulcer,  an  imminent  perforation 
will  be  announced  by  a  recrudescence  of  the  symp- 
toms. It  is  far  more  prone  to  occur  during  a  gastric 
attack  of  more  than  usual  intensity,  and  it  is  most 
uncommon  for  it  to  take  place  without  the  patient 
having  first  noted  an  accentuation  of  some  one 
symptom.  We  have  observed  several  typical  in- 
stances of  this  recrudescence  of  the  symptoms,  pre- 
ceding perforation  by  a  number  of  days.  In  one  case 
a  patient  from  the  country  had  been  treated  upon 
several  occasions  for  symptoms  of  ulcer,  and  as  he 
again  had  experienced  an  exacerbation  of  the  pain 
for  some  days,  he  came  to  Geneva  to  consult  a 
specialist. 

The  specialist,  suspecting  a  serious  chronic  ulcer 
wished  to  examine  into  the  case  more  closely  and 
advised  the  patient  to  enter  a  private  clinic  for  this 
purpose  ;  a  possible  operative  interference  was  even 
mentioned.  Before  returning  home  to  put  his 
affairs  in  order  the  patient  stayed  in  town  the 
remainder  of  the  day.  He  was  suddenly  stricken  in 
the  street  with  severe  abdominal  pain  and  syncope. 
A  physician  was  summoned,  and  proved  to  be  the 
same  who  had  seen  the  patient  shortly  before  in  the 
day  ;  a  diagnosis  of  perforating  gastric  ulcer  with 
peritonitis  was  made,  and  the  patient  was  sent  to 
hospital.  When  he  entered  the  surgical  clinic  the 
diagnosis  was  self-evident,  and  operation  was  imme- 
diately done,  which  revealed  a  chronic  indurated 
gastric  ulcer  with  a  typical  perforation.  In  spite  of 
the  rapid  surgical  act,  the  patient  died  a  few  days 
later  from  gangrenous  broncho -pneumonia. 


266  SURGICAL  TREATMENT 

If  we  have  given  a  summary  of  this  case,  it  is 
merely  because  the  evolution  and  preparation  of  the 
perforation  seem  to  us  absolutely  typical  and 
characteristic.  The  cases  in  which  the  ulcer  has 
perforated  shortly  after  the  patient  has  consulted  a 
physician  are  frequent.  In  fact,  they  are  so  well 
known  that  a  too  careful  examination  on  the  part 
of  the  physician  has  been  supposed  to  be  the  cause 
of  the  accident,  the  passage  of  the  stomach-tube,  or 
even  a  too  energetic  palpation  having  been  the 
factors  ascribed  for  the  perforation.  It  is  clear  that 
too  harsh  manoeuvres  may  have  disastrous  conse- 
quences, but  it  seems  to  us  more  exact  to  suppose 
that  usually  the  patient  goes  to  the  physician 
because  his  ulcer  is  about  to  perforate,  and  not  that 
the  ulcer  perforates  because  the  patient  has  been 
examined  by  a  physician.  There  is  here  a  rather 
marked  distinction  between  the  two  occurrences. 

Less  frequently  perforation  is  announced  by 
haemorrhage  which  precedes  the  fatal  outcome  by 
several  days.  The  loss  of  blood  may  be  so  slight  as 
to  be  overlooked  by  those  who  do  not  take  the 
trouble  to  search  for  it ;  in  other  instances  it  may 
be  of  such  importance  as  to  seriously  react  on  the 
patient's  resistive  powers,  the  need  for  which  is  clear. 

Nevertheless  in  the  majority  of  cases  perforation 
overtakes  the  patient  in  apparently  perfect  health, 
and  although  the  diagnosis  of  peritonitis  is  easy 
enough  to  make,  the  cause  of  the  peritonitis,  which 
is  general  from  the  outset,  is  frequently  difficult  to 
ascertain. 

The  causal  diagnosis  is  even  frequently  impossible  ; 


PERFORATED  GASTRIC  ULCER       267 

in  particular  hesitation  may  be  great  between  a  per- 
forated gastric  ulcer,  appendicitis,  and  gall-bladder. 
Surprises  at  operation  are  not  rare.  In  a  recent 
study  by  Scully  of  forty-eight  gastric  ulcers  that  had 
perforated  the  correct  diagnosis  was  made  twenty- 
one  times,  twice  perforated  duodenal  ulcer  was 
diagnosed,  appendicitis  six  times,  acute  cholecystitis 
three  times,  acute  abdomen  (peritonitis)  thirteen 
times,  ileus  twice,  and  hepatic  abscess  once.  The 
majority  of  these  perforated  gastric  ulcers  occurred 
between  the  ages  of  thirty  and  forty  years.  There 
were  previous  gastric  symptoms  in  thirty-five  of  the 
cases,  and  in  twenty-seven  there  were  premonitory 
symptoms  of  perforation.  It  will  be  seen  from  this 
that  Scully's  findings  have  been  practically  the  same 
as  our  own. 

A  case  was  observed  by  one  of  us  of  a  patient  sent 
to  hospital  with  the  diagnosis  of  strangulated  hernia 
with  symptoms  of  two  days'  standing.  When  the 
hernial  sac  was  incised  pus  and  fibrinous  masses 
mixed  with  undigested  green  vegetables  escaped. 
It  was  thereupon  decided  to  open  the  abdomen. 
This  revealed  a  perforated  gastric  ulcer  which  had 
given  rise  to  general  peritonitis,  this  being  the  cause 
of  the  irreducibility  of  the  hernia,  and  typical  symp- 
toms of  strangulation. 

Hence,  in  a  large  proportion  of  cases,  the  perito- 
nitis is  the  chief  affection  requiring  an  urgent  surgical 
interference.  The  indication  is  clear,  unques- 
tionable. The  cause  of  the  peritonitis  is  secondary, 
but  in  doubtful  cases,  even  when  no  gastric  antece- 
dent is  to  be  found  in  the  anamnesis,  the  possibility 


268  SURGICAL  TREATMENT 

of  a  perforated  gastric  ulcer  should  invariably  be 
considered. 

But  perforation  does  not  always  produce  perito- 
nitis. When  the  previous  inflammatory  attacks 
have  given  rise  to  adhesions,  above  all  when  the 
ulcer  is  seated  on  the  lesser  curvature,  or  on  the 
posterior  aspect  of  the  stomach,  the  general  perito- 
neal cavity  may  escape  infection.  A  localised  peri- 
tonitis results,  or  more  frequently  a  subphrenic 
abscess.  This  is  a  favourable  evolution  of  the 
perforation.  The  abscess  develops  more  slowly, 
becomes  encysted  and  gives  time  for  the  surgeon  to 
interfere  under  better  circumstances. 

These  slow  perforations,  with  subphrenic  abscess 
formation,  are  unfortunately  the  exception.  Their 
treatment  is  somewhat  special,  and  does  not  concern 
us  here.  Let  it  be  said,  however,  that  the  treatment 
consists  of  incision  and  drainage  as  soon  as  the 
patient  has  overcome  the  first  effects,  and  that 
adhesions  have  formed  a  barrier  of  sufficient  resist- 
ance to  allow  the  necessary  manipulations  to  be 
undertaken  without  danger. 

We  will  only  consider  sudden  perforation  with 
generalised  peritonitis,  which,  as  in  all  other  perito- 
nitides,  is  purely  surgical.  The  indications  are 
absolute.  Drainage  must  be  established.  On  this 
point  opinion  is  unanimous.  The  treatment  of  perito- 
nitis need  not  detain  us,  but  what  we  will  discuss  is 
the  treatment  of  the  perforated  ulcer. 

Opinion  widely  differs  in  this  respect,  some  being 
content  with  warding  off  the  first  accidents,  leaving 
for  a  second  interference  the  case  of  dealing  with  the 


PERFORATED  GASTRIC  ULCER        269 

causative  lesion.  Others,  on  the  contrary,  believe 
that  it  is  useless  to  resort  to  operation  if  this  cannot 
offer  sufficient  guarantee  for  the  future.  What  then 
should  be  the  conduct  followed  when  in  the  presence 
of  a  recently  perforated  gastric  ulcer  ? 

All  writers  agree  that  operation  is  urgent.  In 
fact,  the  results  depend  essentially  upon  the  lapse 
of  time  between  the  onset  of  the  accident  and  the 
surgical  act.  They  are  50  per  cent,  better  when 
operation  is  done  within  the  first  twelve  hours  than 
after.  As  in  any  case  of  peritonitis,  it  is  important 
not  to  allow  absorption  of  the  septic  and  toxic 
products  to  take  place.  The  sooner  they  are 
evacuated  by  abdominal  incision  the  better.  But 
although  both  physicians  and  surgeons  are  unani- 
mous in  this  respect,  some  add  a  restriction  which 
only  has,  it  is  true,  a  theoretical  value,  with  some 
very  rare  exceptions.  These  observers  believe  that 
it  is  dangerous  to  operate  when  the  patient  is 
still  shocked.  In  this  state  the  patient  is  in  a 
lessened  condition  of  resistance,  which  will  only 
become  accentuated  if  operation  is  resorted  to  before 
combating  the  shock.  Therefore  the  general  condi- 
tion should  first  be  attended  to  by  the  ordinary 
therapeutical  measures  used  in  shock,  after  which 
operation  may  be  done. 

But  is  there  not  much  precious  time  lost  in  doing 
this,  during  which  the  gastric  contents  flow  into  the 
peritoneal  cavity,  creating  an  extensive  infection  ? 
To  answer  this  question  we  must  first  examine  what 
takes  place  at  the  time  of  the  perforation  and  in  what 
way  the  organism  reacts. 


270  SURGICAL  TREATMENT 

In  the  great  majority  of  cases — no  fixed  rule  can 
be  given — perforation  produces  collapse,  which  may 
even  result  in  syncope,  probably  due  to  reflex  action. 
If  the  patient  be  examined  at  this  time,  the  general 
condition  will  be  found  to  be  serious.  The  pulse  is 
rapid  and  often  so  weak  that  it  cannot  be  counted ; 
respiration  is  superficial,  the  expression  one  of 
distress.  The  patient  will  complain  of  severe  abdo- 
minal pain  with  rigidity  of  the  parietes,  usually  more 
marked  in  the  upper  part  of  the  abdomen,  although 
not  invariably  so,  which,  with  the  other  symptoms, 
imposes  a  diagnosis  of  peritonitis. 

Then  the  strength  progressively  returns ;  the  pulse, 
imperceptible  at  the  onset,  can  now  be  counted  ;  it 
assumes  its  rhythm  and  strength ;  the  abdominal 
pain  subsides  ;  in  a  word,  the  clinical  condition 
becomes  less  alarming.  But  this  condition  is  of 
short  duration,  and  disquieting  symptoms  soon 
return.  The  face  is  sunken,  the  pain  becomes  more 
and  more  acute,  vomiting  ensues,  the  pulse  is  weak, 
and  the  signs  of  peritonitis  noted  at  the  onset  are 
fully  established. 

Usually,  therefore,  when  circumstances  are  such 
that  the  patient  with  a  perforation  can  be  kept  under 
observation  from  the  onset,  three  more  or  less 
distinct  phases  are  to  be  observed  in  the  succession 
of  events,  namely,  (1)  a  phase  of  intense  reaction 
of  the  organism,  (2)  a  phase  of  fallacious  improve- 
ment, and  (3)  a  phase  of  full  development  with 
establishment  of  various  classic  symptoms.  If  an 
attempt  be  made  to  explain  these  different  phases, 
it  can  be  said  that  the  first  corresponds  to  the  action 


PERFORATED  GASTRIC  ULCER        271 

of  sudden  sharp  pain  on  the  general  and  sympa- 
thetic nervous  systems.  The  second  corresponds 
to  the  time  when  this  nervous  depression  has  been 
overcome  and  the  fluid  contents  of  the  stomach 
have  not  yet  made  their  entrance  into  the  peritoneal 
cavity,  at  least  in  sufficient  amount  to  produce 
irritation  of  the  serosa.  Lastly,  the  third  phase 
indicates  the  reaction  of  the  serosa  against  the  irrita- 
tion resulting  from  the  gastric  contents  poured  into 
the  peritoneal  cavity. 

We  desire  to  especially  insist  upon  the  second 
phase,  or  phase  of  remission,  as  it  has  been  the  cause 
of  numerous  mistakes  in  diagnosis  and  is  the  means 
of  losing  much  valuable  time.  The  only  two  writers 
who  have  referred  to  it  to  our  knowledge  are  Mitchell 
and  Miles,  but  we  have  mentioned  it  on  two  occasions, 
once  in  1910  and  again  in  1913.  The  patient's 
condition  improves  little  by  little,  and  although  the 
pain  persists,  it  is  quite  tolerable  ;  its  limits  are  less 
distinct,  and  it  seems  to  extend  throughout  the 
abdomen,  being  usually  more  marked  in  the  right 
iliac  fossa.  The  maximum  of  spontaneous  pain  may 
even  appear  to  have  its  centre  in  the  area  of 
MacBurney's  point,  therefore  leading  to  the  suspicion 
that  appendicitis  may  exist,  and  this  mistake  has 
been  made  many  times.  We  would  insist  upon  the 
fact  that  the  decrease  of  the  pain  is  quite  independent 
of  the  administration  of  morphin  or  other  narcotics 
which  may  have  been  given  at  the  onset  of  the 
process. 

The  very  weak  pulse  becomes  stronger  and  slower ; 
and  although  respiration  is  easier,  it  retains  the 


272  SUEGICAL  TREATMENT 

costal  type.  The  facial  expression  is  one  of  great 
relief,  which  misleads  the  physician  and  the  patient's 
friends.  The  following  case  well  illustrates  the 
condition : — 

Male,  aet.  thirty-six  years,  subject  to  pain  after 
eating  for  several  years  past.  Has  followed  several 
treatments  with  only  temporary  relief.  On  the 
evening  of  March  17th,  1912,  the  patient  was  seized 
with  a  violent  pain  in  the  epigastrium,  and  lost  con- 
sciousness for  several  minutes.  His  physician  found 
him  in  a  serious  condition,  gave  a  hypodermic  of 
caffein,  and  ordered  hot  applications  to  the  abdomen. 
At  midnight,  when  the  patient  was  again  seen,  the 
physician  found  him  better,  the  pain  was  less  severe, 
and  the  greatly  improved  general  condition  elimi- 
nated the  fear  at  first  entertained  that  a  perforation 
had  taken  place.  At  4  a.m.  the  physician  was  again 
summoned.  The  pain  had  become  violent  with 
distinct  abdominal  rigidity.  Operation  was  then 
and  there  advised,  but  the  family  desired  a  consulta- 
tion, thereby  losing  invaluable  time. 

The  patient  entered  hospital  at  11  a.m.  in  a  dis- 
tinctly bad  condition  :  imperceptible  pulse  ;  rapid, 
superficial  respiration ;  abdomen  distended  and 
rigid  ;  cyanosis  of  the  extremities.  Operation  re- 
vealed a  perforated  ulcer  in  the  pylorus  ;  this  was 
sutured,  and  gastroenterostomy  with  a  Murphy 
button  was  done.  Operation  lasted  twenty-six 
minutes.  Stimulants  and  an  injection  of  600  c.c.  had 
no  effect  on  the  heart,  the  patient  dying  at  2.30  p.m. 

Miles  reports  a  similar  case.  A  physician  diag- 
nosed a  perforation  two  hours  after  it  had  occurred, 


PERFOEATED  GASTRIC  ULCER       273 

and  made  arrangements  for  the  patient  to  enter 
hospital.  When  seen  an  hour  later  the  doctor  found 
the  patient  so  much  better  that  he  decided  not  to 
send  him  to  hospital,  thinking  he  had  made  a  mistaken 
diagnosis.  A  few  hours  later  general  peritonitis  had 
become  declared,  and,  in  spite  of  a  hasty  operation, 
the  patient  died. 

During  the  phase  of  remission  the  abdominal 
condition  corresponds  with  the  improved  general 
status.  The  muscles  are  less  tense ;  the  walls 
appear  softer  as  compared  to  what  they  were  at  the 
onset.  However,  pressure  over  the  epigastric  region 
and  pylorus  will  reveal  some  appreciable  rigidity. 
The  area  of  rigidity  always  extends  in  the  direction 
of  the  right  iliac  fossa  up  to  the  neighbourhood  of 
MacBurney's  point.  The  diagnosis  may  be  difficult, 
but  it  is  possible  to  make,  if  not  with  certainty,  at 
least  with  enough  probability  to  make  operation  im- 
perative ;  and  upon  several  occasions  we  have  made 
the  diagnosis  of  perforation  where  others  believed 
the  case  to  be  one  of  appendicitis.  The  phase  of 
remission  is  the  time  to  operate  successfully,  and 
usually  lasts  for  two  to  three  hours. 

These  three  successive  phases  in  the  symptomato- 
logy are  by  no  means  hypothetical ;  we  have  observed 
them  in  cases  of  perforated  ulcer  wrhich  were  directly 
under  our  observation.  In  one  case,  for  example, 
the  patient's  family  refused  immediate  operation, 
and  for  eight  hours  we  were  able  to  follow  the 
successive  appearance  of  the  symptoms  before 
operating.  In  another  case  operation  was  done  two 
hours  and  a  half  after  the  onset  of  the  symptoms,  and 

8.T.  T 


274  SURGICAL   TREATMENT 

explained  the  reason  for  the  improvement  which 
characterises  the  second  phase — phase  of  remission. 

The  data  derived  from  these  and  other  cases 
teach  us  that  at  the  time  of  the  onset  of  the  perfora- 
tion operation  should  be  delayed  until  the  phase 
of  shock  has  been  overcome.  It  is  infinitely  more 
prudent  to  prepare  for  it  by  improving  the  patient's 
general  condition,  after  which  the  surgical  act  can 
be  carried  out  in  far  more  auspicious  circumstances 
when  the  phase  of  remission  is  reached.  Until  then 
the  danger  of  peritonitis  need  not  be  feared,  because 
the  exit  of  the  gastric  contents  into  the  peritoneal 
cavity  is  very  small  in  amount. 

Why  is  it  that  during  this  short  space  of  time  the 
stomach  does  not  expel  its  contents  through  the 
gaping  aperture  in  the  ulcer  ?  Is  it  the  result  of 
inhibition  of  the  organ  that  prevents  it  from  con- 
tracting, or  is  this  momentary  occlusion  only  present 
in  cases  of  ulcer  seated  in  the  pylorus  ?  If  such  is  the 
case,  the  occlusion  can  be  explained  by  spasmodic 
contraction  of  the  prepyloric  antrum  or  of  the  mid- 
gastric  sphincter. 

This  contraction  can  be  compared  to  the  pyloric 
spasm  obtained  experimentally  by  Kelling  by  means 
of  mechanical  excitation  of  the  duodenum.  Both 
these  explanations  of  the  facts  observed  have  each 
their  value  in  each  particular  case,  and  no  particular 
preference  can  be  given  to  either.  It  is  generally 
conceded  (Tuffier)  that  the  small  amount  of  oozing 
of  the  gastric  contents  is  due  to  the  fact  that  the 
organ  is  empty  at  the  time  perforation  takes  place. 
This  does  not  seem  to  us  to  be  exact,  because  we 


PERFORATED   GASTRIC   ULCER       275 

have  observed  one  case  in  which  vomiting  of  food 
and  blood  occurred  after  a  sudden  perforation  had 
taken  place.  The  stomach  tube  removed  one  litre 
and  a  half  of  fluid  of  the  same  nature  as  that  vomited 
an  hour  before.  The  stomach  was  not  empty  at  the 
time  of  the  accident ;  but  at  operation,  performed 
two  hours  later,  there  were  hardly  100  c.c.  of  liquid 
in  the  peritoneal  cavity. 

This  would  seem  to  prove  the  explanation  offered 
above,  but  is  this  true  in  every  case  ?  We  are  not 
prepared  to  be  affirmative  in  this  regard,  and  we 
believe  that  it  is  impossible  for  the  present  to  give 
absolute  preference  to  either  one  of  these  explana- 
tions. Unfortunately  these  phases  are  of  eminently 
variable  duration  according  to  each  case  ;  therefore 
they  cannot  be  counted  upon  with  any  degree  of 
certainty.  In  practice  as  well  the  physician  rarely 
has  the  opportunity  of  waiting  ;  he  will,  so  to  speak, 
never  have  the  time  to  refer  the  case  to  a  surgeon 
ready  to  operate  before  the  advent  of  the  phase 
of  remission.  Therefore  the  rule  should  be  to 
operate,  or  at  least  to  be  ready  for  operation,  as 
quickly  as  possible. 

Finally,  we  would  once  more  refer  to  the  deceitful 
appearance  of  this  phase,  and  conclude  that  one 
should  never  be  led  astray  by  the  momentary 
remission  of  the  symptoms,  but,  on  the  contrary, 
profit  by  this  phase  for  operating  in  better  con- 
ditions. 

To  conclude,  we  would  say  that,  generally  speaking, 
the  operative  act  should  be  accomplished  as  soon  as 
a  perforation  has  been  diagnosed.  Usually  there 

T  2 


276  SURGICAL  TREATMENT 

need  be  no  fear  of  entrance  of  the  gastric  contents 
into  the  peritoneal  cavity  during  the  phase  of  shock, 
because  at  most  it  will  be  very  small  in  amount,  and 
even  does  not  occur  at  all  in  many  cases  during  a 
lapse  of  time  varying  from  one  to  two  and  a  half 
hours.  One  should  profit  as  much  as  possible  by 
this  fallacious  remission  of  the  symptoms,  which 
usually  follows  the  first  phase,  to  operate  in  fairly 
good  circumstances. 

Choice  of  the  Procedure. — The  surgical  act  should 
treat  two  very  distinct  conditions,  namely,  peritonitis 
and  ulcer.  Therefore  it  must  deal  at  the  same  time 
with  both  conditions  in  order  to  fulfil  its  indications 
completely,  but  one  of  them,  the  peritonitis,  requires 
urgent  and  rapid  interference,  while  ulcer  demands  a 
long,  laborious  operation  if  the  lesion  is  to  be  correctly 
dealt  with.  The  ideal  is  consequently  an  operation 
which  can  be  quite  quickly  carried  out,  exacting 
only  the  strict  minimum  of  resistance  on  the  patient's 
part,  and  yet  to  properly  deal  with  the  perforation 
to  avoid  further  contamination  of  the  peritoneum. 

We  shall  refer  to  some  of  the  details  further  on, 
but  we  would  here  say  that  Murphy's  principle  is 
now  more  generally  accepted,  which  maintains  that 
in  cases  of  peritonitis  one  should  get  in  and  get  out 
of  the  peritoneal  cavity  as  quickly  as  possible. 
This  precept  should  be  followed,  perhaps,  more  to 
the  letter  in  cases  of  perforated  gastric  ulcer  than 
in  peritonitides  of  other  origin,  because  the  surgeon 
is  more  tempted  to  resort  to  a  long  surgical  act, 
which  may  seem  to  offer  greater  security  against  the 
secondary  risks  of  ulcer. 


PERFORATED  GASTRIC  ULCER       277 

In  perforated  ulcer  there  is  a  choice  between  : — 

Resection ; 

Suture  of  the  ulcer,  with  or  without  omental 
flaps ; 

Suture  of  the  ulcer  and  gastroenterostomy ; 

Simple  gastroenterostomy ; 

Gastrotomy ; 

Simple  gauze  packing. 

To  indicate  which  of  these  procedures  is  to  be 
preferred  is  impossible.  More  than  anywhere  else, 
the  special  circumstances  inherent  to  each  case  here 
play  a  considerable  part.  Therefore  there  is  no 
fixed  rule  ;  the  operator  must  be  guided  by  the 
inspiration  of  the  moment.  Nevertheless  we  will 
briefly  examine  the  particular  advantages  of  each  of 
these  procedures. 

Resection. — When  considering  resection  in  regard 
to  the  various  indications  of  ulcer  we  pointed  out 
that  this  operation  should  often  be  rejected  on 
account  of  the  dangers  accruing  from  its  long  dura- 
tion and  traumatising  action.  Typical  resections  in 
particular,  such  as  pylorectomy  and  annular  gastrec- 
tomy,  cannot  be  taken  into  serious  consideration. 
Atypical  resections — those  often  called  simple  exci- 
sions of  the  ulcer — are,  on  the  other  hand,  frequently 
practised.  To  close  the  perforation  one  may  be 
compelled  to  excise  the  callous  edges  in  order  to 
introduce  the  sutures,  otherwise  they  would  cut 
through  the  friable,  indurated  tissues,  and  the  opening 
could  not  be  closed  or  coaptation  of  the  edges  effected. 
The  indurated  area  may  be  too  extensive  for  it  to  be 
possible  to  infold  the  ulcer,  and  consequently  the 


278  SURGICAL  TREATMENT 

only  procedure  which  would  seem  to  give  some 
security  is  excision  of  the  callous  mass  and  suture  in 
healthy  structures. 

This  procedure  can  be  carried  out  quickly  when 
circumstances  are  favourable.  Well-placed  sutures, 
with  doubling  over  of  the  serous  membrane,  offer 
sufficient  guarantee.  This  should  be  the  operation  of 
choice  were  it  not  for  the  fact  that  favourable  con- 
ditions for  its  execution  are  rarely  present.  In  the 
majority  of  cases  the  induration  is  very  extensive, 
partially  covered  by  adhesions,  the  breaking  up  of 
which  will  often  present  serious  difficulty. 

On  the  other  hand,  the  repair  of  lost  substance 
which  results  from  excision  of  the  periulcerous  tissue 
leads  to  complicated  plastic  operations.  Only  too 
often  the  ulcer  seated  at  the  pylorus  or  on  the  lesser 
curvature  prevents  excision  even  when  carefully 
calculated,  because  it  would  inevitably  result  in  the 
formation  of  a  secondary  stenosis.  Therefore,  if 
excision  is  done  in  these  areas,  it  must  be  completed 
by  gastroenterostomy.  The  circumstances  creating 
these  disadvantages  are  not  exceptional ;  they  are, 
on  the  contrary,  those  that  are  encountered  in  the 
majority  of  cases.  Consequently  resection  or  simple 
excision  of  the  edges  of  the  perforation  should  only 
be  considered  as  exceptional  procedures,  to  be 
reserved  for  particularly  favourable  cases. 

Suture  of  the  Perforation. — The  simplest  and  at  the 
same  time  the  most  rapid  way  of  treating  the  per- 
foration is  certainly  by  direct  suture.  Unfortunately, 
as^we  have  already  said,  the  sutures  are  not  solid, 
placed  as  they  are  in  tissues  which  have  lost  their 


PEEFOEATED  GASTEIC  ULCEE       279 

softness  and  cannot  be  mobilised,  while  at  the  same 
time  they  are  extremely  friable.  Therefore,  even 
when  the  opening  has  been  successfully  closed,  there 
is  no  guarantee  as  to  the  ulterior  fate  of  the  suture, 
and  with  each  contraction  of  the  stomach  perforation 
is  very  likely  to  recur. 

Finally,  it  even  happens  that  the  tissues  are  so 
bad,  and  the  edges  of  the  perforation  so  gaping, 
that  an  attempt  at  coaptation  is  useless.  In  these 
circumstances,  after  closing  the  opening  as  far  as 
possible,  complete  the  occlusion  by  borrowing  from 
some  adjacent  organ  the  necessary  material  for  this 
purpose.  Usually  a  piece  of  omentum  is  selected  and 
sutured  over  the  gap,  but  the  mesocolon  or  even  the 
colon  itself  can  be  used,  likewise  the  edge  of  the  liver, 
according  to  the  site  and  relationships  of  the  ulcer. 

These  two  procedures  of  direct  suture  or  oblitera- 
tion by  autoplasty  seem  at  first  sight  to  offer  little 
security.  In  practice,  however,  they  have  been  found 
to  be  quite  sufficient,  especially  if  care  be  taken,  in 
some  cases,  to  do  gastroenterostomy  at  the  same 
time.  The  latter  procedure  will  be  indispensable 
when  the  perforated  ulcer  is  seated  at  the  pylorus 
and  already  forms  a  stricture  that  could  only  be 
exaggerated  by  sutures. 

When  the  perforation  takes  place  on  the  anterior 
wall  of  the  stomach  suturing  will  usually  be  both 
easier  and  surer.  It  will  be  possible  to  reinforce  the 
sutures  by  infolding  the  peritoneum  over  them  with 
a  purse-string  suture,  which  will  give  greater  resist- 
ance to  the  occlusion  of  the  perforation.  At  the 
same  time  gastroenterostomy  has  less  effect ;  it  is 


280  SUEGICAL  TREATMENT 

little  help  to  the  stomach  for  carrying  on  its  functions, 
and  therefore  is  less  indicated. 

Simple  suture  is  a  rapid  operation,  requiring  but  a 
few  minutes.  Therefore,  when  necessary,  there  is 
little  added  risk  in  completing  it  by  a  complementary 
operation,  such  as  gastroenterostomy,  which  when 
done  with  a  Murphy  button  requires  less  time  than 
it  takes  for  exclusion.  The  two  combined  operations 
can  usually  be  done  in  less  time  than  a  resection. 

This  procedure  is,  for  that  matter,  the  one  most 
commonly  employed  ;  it  is  applicable  in  the  majority 
of  circumstances,  and  we  do  not  hesitate  to  regard  it 
as  the  method  of  choice,  and  only  infrequently  will 
excision  and  secondary  suture  be  preferred.     No 
hesitation   is   permissible   when   the   ulcer   is   well 
limited   and   seated   on   the   anterior   gastric   wall, 
therefore  when  there  is  little  loss  of  tissue  and  an 
aperture  easily  accessible.    In  the  majority  of  other 
cases  it  is  certainly  to  direct  suture  with  or  without 
gastroenterostomy  that  preference  should  be  given. 
Let  us  add  that  in  pyloric  ulcers,  where  it  is  well  to 
do  a  gastroenterostomy,  no  attempt  should  be  made 
to  preserve  the  permeability  of  the  gastro-duodenal 
opening.    On  the  contrary,  it  will  be  a  good  thing  to 
favour  stenosis  of  this  canal,  because  one  will  be  thus 
assured  of  proper  functioning  of  the  stoma.    These 
sutures  are  inserted  transversally,  and  are  easy  to  do, 
and  the  more  they  tighten  the  pylorus  the  better. 

According  to  the  same  principle,  exclusion  of  the 
pylorus  or  prepyloric  region  may  be  done,  but 
always,  of  course,  combined  with  gastroenterostomy. 
Unfortunately  this  operation  is  rather  long  to  carry 


PERFORATED  GASTRIC  ULCER       281 

out  and,  from  this  fact,  is  not  particularly  recom- 
mendable  in  cases  of  perforated  gastric  ulcer.  It 
might,  however,  be  useful  when  it  has  been  found 
to  be  impossible  to  close  the  pyloric  or  duodenal 
perforation.  In  duodenal  perforation  the  aperture  is 
separated  from  the  stomach,  so  that  only  the  trifling 
contents  of  the  duodenum  will  flow  out,  and  they  can 
be  dealt  with  by  proper  drainage.  Nevertheless  this  is 
only  an  operation  of  fortune,  which  does  not  give  any 
very  great  security  and  presents  the  disadvantage 
of  being  very  long  and  frequently  laborious  whenever 
the  pyloric  region  is  surrounded  by  adhesions.  It 
merits,  however,  mention. 

When  the  perforation  can  be  sutured,  exclusion  of 
the  pylorus  seems  to  us  to  be  too  serious  an  operation 
for  one  to  decide  upon  it  then  and  there.  Gastro- 
enterostomy  should  in  itself  sufficiently  assure 
momentary  rest  of  the  pyloric  region  for  the  sutures 
to  hold.  Pyloric  exclusion  can  be  done  with  profit  at 
a  second  interference  when  the  subject  has  recovered 
from  his  peritonitis.  It  will  then  be  useful,  necessary 
in  some  cases,  to  assure  both  the  cure  of  the  ulcer 
and  the  permanent  patency  of  the  stoma.  Lastly, 
besides  these  typical  procedures — classic,  so  to  speak 
— certain  occasional  operations  should  be  mentioned 
which  have  been  performed  in  special  circumstances. 
Thus  the  perforation  may  be  in  such  a  position,  on 
the  greater  curvature,  for  example,  that  the  opening 
has  been  used  in  the  gastroenterostomy.  Although 
this  procedure  is  ingenious,  we  do  not  see  that  it  offers 
any  real  advantages.  It  is  not  absolutely  secure  in 
results.  The  sutures  of  the  anastomosis,  placed  in 


282  SURGICAL  TREATMENT 

indurated  tissues,  will  resist  poorly  the  dragging  of 
the  intestine.  If,  on  the  contrary,  the  edges  of  the 
perforation  are  not  indurated,  so  that  there  will  be 
no  tendency  for  the  sutures  to  cut  through,  excision 
of  the  ulcer  can  be  easily  done,  or  even  simple  suture. 
This  is  all  the  more  indicated  because  if  the  perfora- 
tion is  to  be  used  in  the  anastomosis  the  aperture 
must  of  necessity  be  seated  at  a  point  easily  accessible. 
Hence  in  these  circumstances  we  unquestionably 
prefer  the  ordinary  procedures — excision  and  suture, 
simple  suture  or  suture  with  gastroenterostomy. 

The  perforation  has  been  utilised  in  making  a 
gastrostomy.  This  procedure,  which  offers  about  the 
same  disadvantages  as  the  preceding  one,  has  the 
advantage  of  feeding  the  patient  more  quickly, 
especially  if  care  be  taken  to  pass  the  sound  beyond 
the  pylorus.  But  we  question  this  advantage  when 
treatment  of  the  peritonitis  implies  complete  rest  of 
the  intestine. 

Finally,  the  simplest  means,  but  also  the  most 
risky,  is  to  leave  the  perforation  open  and  be  content 
with  drainage.  In  certain  cases  it  has  been  found 
necessary  to  confine  the  surgical  act  to  this  procedure, 
and  surgeons  have  been  astounded  in  witnessing  the 
recovery  of  the  patients  so  treated.  This,  at  least, 
teaches  us  that  the  best  procedures  are  always  the 
simpler  ones,  therefore  the  most  quickly  carried  out, 
and  that  one  should  be  chary  of  complete  operations, 
theoretically  ideal,  but  too  long  and  too  traumatising 
for  patients  with  little  resistance. 

As  to  the  treatment  of  the  peritonitis,  we  need  not 
speak,  as  it  is  that  of  all  peritonitides.  Free  drainage 


PERFORATED  GASTRIC  ULCER       283 

and  Fowler's  position  are  necessary,  and  it  is  useless 
to  attempt  cleansing  the  peritoneal  cavity  thoroughly. 
Flushing  out  to  any  extent  is  to  be  decried.  When 
the  perforation  is  recent  and  the  gastric  contents 
contained  in  the  peritoneum  are  trifling  and  localised, 
they  may  be  removed,  but  in  so  doing  any  superfluous 
trauma  must  be  avoided. 

The  general  treatment,  cardiac  stimulants  and, 
above  all,  salt  solution  injections  frequently  repeated, 
should  be  closely  followed.  Murphy's  rectal  method 
has  but  one  disadvantage,  namely,  that  it  is  not 
always  tolerated  and  demands  close  supervision. 


CHAPTER  XI 

GASTRIC   DYSTOPIAS 

IN  a  general  way  it  may  be  admitted  that  there  are 
three  principal  classes  of  change  in  the  position  of 
the  stomach,  namely,  (1)  the  ptoses  in  general, 
(2)  hernias  of  the  stomach,  and  (3)  volvulus.  The 
ptoses  are  by  far  the  most  frequent ;  they  are 
encountered  in  practice  so  often  that  from  this  very 
fact  they  offer  a  real  interest.  They  likewise  are  of 
special  interest  to  the  surgeon,  because  although  the 
majority  are  suitable  for  medical  treatment,  which, 
when  properly  carried  out,  will  result  in  recovery,  or 
at  least  a  decided  improvement,  medical  means  may 
sometimes  fail,  and  then  the  question  of  operation 
may  come  up,  the  indications  for  which  are  still  moot. 
Hernia  and  volvulus  of  the  stomach  are  such  patho- 
logical rarities  that  a  surgeon  may  not  meet  with  a 
case  in  his  career,  and,  the  treatment  being  absolutely 
surgical,  no  discussion  is  necessary. 

Ptoses  in  General. — Two  varieties  of  gastric  ptoses 
are  met  with  which  are  principally  differentiated  by 
their  anatomical  position  and  pathogenesis,  their 
symptoms  and  treatment  being  practically  the  same. 
These  two  varieties  are  (1)  vertical  dislocation  and 
(2)  gastric  ptosis  in  the  strict  sense  of  the  term. 

Vertical  Dislocation. — This  is  a  partial  ptosis  of 
the  stomach  in  which  the  pyloric  portion  is  alone 


GASTRIC  DYSTOPIAS  285 

involved,  the  cardiac  portion  remaining  fixed.  If  the 
anatomy  and  means  of  suspension  of  the  stomach  be 
examined,  it  will  be  found  that  the  organ  is  strongly 
fixed  by  its  upper  or  cardiac  portion  to  the  diaphragm. 
The  pylorus,  which  for  a  long  time  was  supposed  to 
be  fixed,  is,  on  the  contrary,  rather  movable,  and 
this  mobility  permits  it  to  sag  down  as  far  as  the 
third  lumbar  vertebra.  This  sinking  brings  it  over 
to  the  median  line,  so  that  the  entire  organ  becomes 
progressively  more  vertical,  hence  the  name  given 
to  this  variety  of  position.  If  we  now  consider  the 
consequences  of  this  rotation  of  the  organ,  it  will  be 
seen  that  the  sagging  of  the  pylorus  brings  down  the 
first  portion  of  the  duodenum  as  well,  which  is  also 
movable,  while  the  second  portion  remains  solidly 
fixed  ;  a  sufficiently  marked  bend  results  to  offer 
an  obstacle  to  the  transit  of  the  gastric  contents. 

This  obstacle  creates  a  certain  degree  of  stasis 
which  acts  almost  exclusively  on  the  pyloric  antrum, 
transforming  it  into  a  cul-de-sac,  and  not  uniformly 
throughout  the  viscus.  The  pyloric  portion  of  the 
stomach  progressively  dilates,  carrying  the  greater 
curvature  along  with  it,  which  finally  may  descend 
as  far  as  the  pubis  or  to  the  entrance  of  the  pelvis. 
Dilatation  becomes  almost  inevitably  superadded  to 
the  dislocation. 

Many  observers,  among  others  Mathieu  and  J.  C. 
Roux,  do  not  admit  this  type  of  vertical  ptosis, 
because  of  the  fixity  of  the  suspensory  ligaments  of 
the  cardia  and  greater  tuberosity.  They  maintain 
that  there  are  no  special  causes  for  this  vertical 
dislocation.  On  the  contrary,  they  who  admit  the 


286  SURGICAL  TREATMENT 

possibility  of  a  general  ptosis  believe  that  the  cause 
of  this  change  of  position  is  quite  particular  and 
should  be  looked  for  especially  in  constriction  of  the 
lower  portion  of  the  thorax,  hence  the  name  of 
"  corset  disease  "  formerly  given  it  by  some  writers. 
Further  on  we  shall  refer  to  the  pathogenesis  of 
ptoses  in  general,  this  subject  being  the  most  im- 
portant point  to  be  familiar  with  if  a  judicious 
treatment  is  to  be  carried  out. 

In  gastric  ptosis,  strictly  speaking,  the  entire 
stomach  sags  ;  the  portion  of  the  cardia  leaves  its 
normal  position,  and  follows  the  rest  of  the  organ  in 
its  drop.  The  lesser  curvature,  instead  of  becoming 
vertical,  retains  its  oblique  direction  ;  the  pylorus, 
bringing  the  first  portion  of  the  duodenum  with  it, 
drops  without  approaching  the  median  line  to  any 
notable  degree,  and  the  second  fixed  portion  of  the 
duodenum  forms  a  bend  and  an  obstacle  to  the 
evacuation  of  the  stomach.  Phenomena  of  stasis 
then  result,  causing  gastric  dilatation,  just  as  occurs 
in  vertical  dislocation. 

It  should  be  recalled  that  many  writers  do  not 
admit  this  variety  of  ptosis,  sometimes  called  hori- 
zontal dislocation.  But  all  this  is  merely  theoretical 
discussion,  the  consequences — stasis,  dragging  and 
dilatation — being  the  same. 

Pathogenesis. — The  pathogenesis  of  gastric  ptoses 
has  been  much  discussed,  and  at  present  several  and 
varied  causes  are  supposed  to  produce  them.  Long 
since  Cruveilhier  recognised  the  influence  of  corsets, 
which  by  binding  the  waist  provoked  sagging  and 
a  change  of  position  of  the  liver  and  stomach,  but 


GASTRIC  DYSTOPIAS  287 

it  was  only  much  later  that  Kussmaul,  and  afterwards 
Glenard,  seriously  called  attention  to  gastric  ptosis 
and  abdominal  ptoses  in  general.  Glenard  in  par- 
ticular imparted  to  this  affection  an  importance 
that  had  not  been  previously  given  it.  He  sought 
more  especially  for  the  causes,  and  explained  them 
in  such  a  precise  fashion  that  even  those  who  did  not 
completely  accept  his  theories  were  forced  to  recognise 
their  worth.  In  point  of  fact,  an  attempt  should  not 
be  made  to  explain  all  cases  of  ptosis  by  the  same 
mechanism ;  this  would  be  an  error  that  would 
result  in  many  serious  mistakes  in  therapeutics. 
The  causes  are  many,  and  merit  being  studied, 
because,  although  they  may  not  directly  interest  the 
surgeon,  he  cannot  ignore  them  without  exposing 
himself  to  surgical  failure.  It  is  not  our  purpose  to 
discuss  this  subject  at  length,  because  it  will  be 
found  completely  developed  in  modern  works  on 
gastric  and  intestinal  pathology  ;  therefore  we  shall 
be  brief. 

According  to  Glenard,  ptosis  of  the  abdominal 
viscera  and  stomach  is  due  to  a  more  or  less  sudden 
decrease  in  the  size  of  the  abdominal  organs.  The 
most  striking  example  is  that  of  labour.  The 
stomach  is  not  suspended  to  the  upper  part  of  the 
abdomen,  but  is  supported  by  all  the  organs  situated 
underneath  it,  which  play  the  part  of  a  cushion.  If 
for  some  reason  or  other — sudden  emaciation  or 
confinement — this  cushion  diminishes  in  size,  the 
stomach,  being  no  longer  supported,  will  begin  to 
sag. 

It  is  by  the  same  mechanism  that  gastric  ptosis 


288  SURGICAL  TREATMENT 

may  ensue  from  relaxation  of  the  abdominal  parietes 
which  maintain  intra-abdominal  pressure.  Kelling 
points  out  that  the  so-called  suspensory  ligaments 
are  quite  able  to  fix  the  abdominal  organs  backward, 
but  not  to  support  them.  This  cause  is  found 
principally  in  females  who  are  worn  out  by  several 
repeated  pregnancies,  which  have  also  distended  the 
abdominal  parietes,  and  also  in  patients  convalescing 
from  serious  illness,  in  particular  typhoid  fever. 

Finally,  considerable  importance  is  attributed  to 
constriction  of  the  thorax  and  upper  part  of  the 
abdomen,  especially  by  corsets.  It  is  certain  that 
the  great  majority  of  women  afflicted,  not  only  with 
gastroptosis — which  rarely  exists  alone — but  with 
general  splanchnoptosis,  clearly  present  a  special 
conformation  of  the  thorax.  The  thorax  is  elongated 
and  narrow,  which  is  made  evident  by  a  decrease 
of  the  costal  angle  which  at  once  strikes  the  observer. 
The  liver,  which  cannot  decrease  in  size,  not  finding 
the  requisite  space  of  breadth,  elongates  and  descends 
well  below  the  costal  margin  ;  it  takes  the  place  of 
the  abdominal  organs,  and,  in  particular,  causes  the 
stomach  to  swing  over  by  pushing  the  pylorus  down 
to  a  much  lower  level  than  normal. 

Many  writers  have  accused  the  corset  of  being  the 
cause  of  this  thoracic  deformity,  and  have  rendered 
it  responsible  for  it.  We  have  already  seen  that  some 
observers  do  not  hesitate  to  call  vertical  dislocation 
of  the  stomach  "  corset  disease."  Unquestionably 
this  is  a  striking  and  picturesque  denomination,  but 
to  us  it  is  inexact.  The  narrowness  of  the  thorax  has 
clearly  a  considerable  influence  over  the  position  of  the 


GASTKIC  DYSTOPIAS  289 

abdominal  viscera,  in  particular  those  which  are 
in  intimate  relation  to  the  liver,  like  the  stomach  and 
right  kidney.  But  this  conformation  is  congenital  in 
origin,  and  depends  essentially  upon  the  development 
of  the  body  without  the  corset  playing  as  important 
a  part  as  has  generally  been  admitted.  If  a  woman 
has  the  figure  of  a  wasp,  it  is  because  she  was  born 
with  it,  just  as  another  may  have  a  short  figure  from 
birth.  The  corset  has  no  part  in  the  shaping  of  these 
women,  or,  at  least,  its  influence  must  be  trifling.  A 
narrow  thorax  and  small  waist  are  frequently  found 
in  women  who  have  never  worn  corsets,  as  is  to-day 
the  fashion,  and  in  women  of  tropical  countries  who 
have  never  even  worn  clothes  there  is  quite  as  large 
a  proportion  of  wasp-shaped  figures  as  among 
civilised  women.  But  what  is  more  to  the  point  is 
that  in  women  of  tropical  countries  splanchnoptosis 
has  been  found  as  frequently  as  in  hospital  statistics 
of  European  cities. 

This  does  not  imply  that  corsets  cannot  in  certain 
cases  exercise  a  pernicious  compression,  but  such  cases 
are  far  more  rare  than  has  been  supposed,  and  are  only 
in  an  insignificant  minority.  This  same  mechanism 
may  also  be  produced  if,  as  Bouveret  has  observed, 
the  thorax  being  insufficient,  the  liver  increases  in 
size  and  pushes  away  the  kidney  and  stomach. 

Thus  in  a  general  way  it  should  be  admitted  that 
the  most  frequent  cause  of  gastroptosis  is  a  pushing 
aside  of  the  stomach  by  the  liver  and,  whether  or 
not  the  result  of  a  special  anatomical  conformation 
of  the  thorax,  by  an  increase  in  the  size  of  this  organ 
or  the  wearing  of  too  tight  corsets. 


290  SUEGICAL  TEEATMENT 

Finally,  there  is  still  another  factor  which  has  its 
importance,  and  often  accompanies  the  others,  giving 
them  freer  action.  This  factor  is  congenital,  namely, 
a  predisposition  made  manifest  by  an  insufficiency 
of  the  fibrous  and  muscular  tissues  of  the  body. 
These  subjects  are  readily  afflicted  by  hernise  and 
venous  ectasis,  which  reveals  the  true  cause  of  their 
splanchnoptosis. 

Consequences  of  Gastroptosis. — The  first  conse- 
quence of  gastroptosis  is  to  create  an  obstacle  to 
gastric  evacuation  from  a  bend  of  the  duodenum 
rather  than  of  the  pylorus.  This  difficulty  of  the 
stomach  in  emptying  itself  requires  more  energetic 
work  on  the  part  of  the  organ,  which  sooner  or  later 
is  prone  to  become  fagged  out.  A  stasis  ensues,  with 
all  its  consequences,  viz.,  hyperfunctioning  of  the 
mucosa  with  hyperchlorhydria  followed  by  glan- 
dular atrophy  and  consequently  a  diminution  of  the 
digestive  power. 

But  if  in  gastroptosis  a  careful  search  be  made, 
one  will  not  be  long  in  coming  to  the  conclusion  that 
a  number  of  otherwise  perfectly  healthy  men  and 
women  have  ptosis  of  the  stomach  or  vertical 
dislocation  of  the  organ  even  to  a  pronounced  degree. 
Why  do  these  subjects  escape  the  consequences, 
frequently  disastrous,  that  we  have  been  discussing  ? 

It  is  now  becoming  more  and  more  evident  that 
the  ptosis  gives  rise  to  serious  symptoms  or  simply 
disagreeable  sensations  in  those  who  are  predisposed. 
On  the  one  hand,  the  muscularis  of  the  stomach  must 
be  wanting  in  tonicity,  becoming  distended  instead  of 
reacting  against  the  difficulty  that  it  encounters,  thus 


GASTRIC  DYSTOPIAS  291 

leading  to  dilatation  ;  on  the  other,  the  nervous 
system,  particularly  irritable,  must  be  easily  im- 
pressed by  dragging  on  the  gastric  ligaments.  It  is 
for  this  reason  that  Mathieu  says  that  "  one  does  not 
suffer  from  the  splanchnoptosis,  and  consequently  a 
gastroptosis,  unless  he  is  predisposed,  and  clinical 
observation  demonstrates  that  this  predisposition 
essentially  consists  of  the  previously  existing  neuro- 
pathy of  the  subject." 

As  an  immediate  consequence  of  the  ptosis, 
dragging  on  the  gastric  ligaments  becomes  super- 
added  to  the  gastric  dilatation,  which  provokes  pain 
from  irritation  of  the  nerve  filaments,  which  are  so 
developed  in  these  folds  of  the  serosa.  But  to  these 
pains,  which  increase  with  every  movement,  by 
walking  or  standing,  other  more  obscure  and, 
perhaps,  indeterminate  disturbances  become  added, 
and  are  often  even  more  serious.  The  continual 
irritation  of  the  nerve  filaments  and  of  the  sympa- 
thetic plexus  reflects  on  the  patient's  general  health. 
Hence  the  intimate  and  frequent  relations  connecting 
gastroptosis  with  neuropathic  states. 

Gastroptosis  can  perfectly  well  engender  neuro- 
pathies, but  this  can  only  occur  in  predisposed 
individuals.  The  gastroptosis  must  often  first  take 
place  in  order  that  the  neuropathy,  until  then  latent, 
shall  appear,  with  all  its  consequences  and  symptoms. 

The  conclusion  to  be  drawn  from  what  has  been 
said  is  that  gastroptosis  is  a  complex  process  whose 
causes  are  varied,  and  which  does  not  give  rise  to 
symptoms  until,  from  a  special  anatomical  or  nervous 
predisposition,  its  direct  consequences  can  be  pro- 

u  2 


292  SUKGICAL  TBEATMENT 

duced,  particularly  gastric  dilatation  and  neuro- 
pathy. 

Treatment. — There  is  very  little  to  say  in  respect 
to  surgical  treatment  of  gastroptosis.  The  surgeon 
will  have  such  rare  opportunity  to  interfere  that 
Mathieu,  Eobin  and  Koux  assume  that  it  is  needless 
to  discuss  the  subject. 

In  the  majority  of  cases  the  treatment  of  gastro- 
ptosis is  purely  medical,  and  depends  especially 
upon  the  cause  giving  rise  to  the  affection.  However, 
although  at  present  the  utility  of  operations  for  the 
relief  of  gastroptosis  is  generally  regarded  as  contra- 
indicated,  this  is  not  invariably  the  case.  There  even 
was  a  time,  when  surgical  treatment  of  affections  of 
the  stomach  was  in  its  infancy,  when  surgeons 
thought  that  interference  was  quite  legitimate.  The 
results,  which  at  the  onset  appeared  to  fulfil  the  most 
exacting  expectations,  were  of  short  duration,  and 
were  finally  found  to  give  little  encouragement. 

Consequently  one  surgeon  after  another  discarded 
operative  treatment,  and  decided  to  have  recourse 
to  it  only  when  all  other  therapeutical  measures  in 
cases  of  exceptional  gravity  failed.  As  we  have  said, 
the  treatment  is  to  be  particularly  directed  against 
the  cause  of  the  gastroptosis,  and  in  the  great  majority 
of  cases  the  cause  is  too  general  to  be  reached  by 
operation.  All  the  procedures  devised  can  only  be 
a  symptomatic  treatment,  while  the  affection  is  too 
complex  for  any  operation  to  have  the  slightest 
influence  ;  above  all,  the  neuropathic  element  is  too 
important  for  any  effective  results  to  be  hoped  for. 

Now,  if  in  general   medical   treatment  is   more 


GASTRIC  DYSTOPIAS  293 

effective  in  gastroptosis,  there  are  nevertheless  cases 
in  which  operation  has  been  the  only  treatment  that 
has  resulted  not  only  in  complete,  but  also  durable, 
recovery. 

The  cases  that  are  suitable  for  an  interference  are 
those  in  which  the  gastroptosis  has  produced  a  real 
obstacle  to  gastric  evacuation  from  a  bend,  an 
obstacle  which  cannot  be  overcome  by  contractility 
of  the  muscularis,  although  this  may  be  intact. 
Consequently  when  phenomena  of  stasis  with  a 
stomach  in  a  state  of  ptosis  are  met  with,  and  without 
a  too  accentuated  atony  of  the  muscularis,  an 
operation  for  the  relief  of  the  condition  can  be 
seriously  considered.  When,  on  the  contrary,  the 
stomach  is  already  paretic,  allowing  easy  dilatation — 
and  this  is  what  is  most  frequently  encountered  in 
practice — operation  is  useless  and  doomed  to  almost 
certain  failure.  The  fact  is  that,  in  these  cases,  the 
neuropathic  state  is  too  much  changed  and  holds  a 
preponderant  place  in  the  affection. 

The  same  may  be  said  when  all  internal  thera- 
peutical measures  have  been  tried  in  vain.  When, 
at  the  end  of  his  resources,  the  physician  sees  cachexia 
developing,  he  may,  as  Lyon  appears  to  advise, 
suggest  an  attempt  at  relief  by  surgical  treatment. 
It  may  be  attempted,  but  we  personally  do  not 
believe  that  it  is  to  be  recommended,  because  little 
can  be  expected  from  an  operation  undertaken  in 
such  circumstances. 

Choice  of  the  Procedure. — As  has  been  said,  the 
treatment  of  ptosis  should  be  aimed  less  at  the 
affection  itself  than  its  causative  factors.  There  is 


294  SURGICAL  TREATMENT 

not  a  single  operation  that  can  attain  this  end  ; 
we  do  not  possess  in  surgery  a  single  means  for 
restoring  the  tonus  of  the  fibromuscular  tissues  of 
the  abdominal  parietes,  nor  is  there  anything  that 
the  surgeon  can  do  to  increase  the  space  for  abdominal 
organs  compressed  by  a  narrow  thorax.  Therefore 
all  that  can  be  done  is  to  remedy  an  anatomical  result 
of  these  causes,  or  to  obviate  the  physiological 
consequences  that  may  ensue. 

There  are  consequently  two  ways  of  proceeding. 
The  first  is,  so  to  speak,  anatomical,  as  it  attempts 
to  retain  the  stomach  in  its  normal  site  ;  the  second 
has  for  aim  the  re-establishment  of  the  gastric 
functions  without  in  any  way  changing  the  patho- 
logical position  of  the  organ.  Finally,  since  neither 
of  these  procedures  is  capable  of  giving  sufficient 
guarantee,  the  possibility  of  increasing  the  chances 
of  success  has  been  attempted  by  combining  them. 
From  these  principles  the  following  operations  have 
been  essayed  : — 

Gastropexy. 

Gastropexy  with  or  without  gastroplication. 

Gastro-entero-anastomosis. 

Gastropexy  with  gastroenterostomy. 
Gastropexy. — This  is  a  simple  procedure,  quickly 
carried  out,  and  for  this  reason  rather  tempting. 
It  has  given  some  very  good  results,  especially  to  its 
promoter,  Bircher,  and  also  at  the  hands  of  other 
surgeons.  It  places  the  stomach  in  its  normal 
position,  and  the  result  has  been  the  regulating  of 
gastric  motility  and  emptying  of  the  stomach. 
Unfortunately  the  operation  presents  two  objections, 


GASTRIC  DYSTOPIAS  295 

with  the  result  that  many  have  discarded  it  or,  at 
least,  regard  it  as  insufficient  in  its  effects. 

The  first  of  these  objections  is  that,  in  spite  of 
the  improvements  in  technique  since  devised  by 
Bircher,  the  pexia  is  not  secure  and  recurrences  are 
frequent.  This  is  not  surprising,  because  the  causes 
of  the  ptosis  subsist,  and  it  is  clear  that  it  cannot  do 
otherwise  than  recur.  It  is  therefore  absolutely 
necessary,  even  after  operation,  to  carry  out  a 
rigorous  treatment  directed  to  the  increase  of  the 
tonus  and  also  to  give  greater  resistance  to  the 
abdominal  parietes.  This  treatment,  unable  to 
give  any  results  before  operation  on  account  of  the 
disturbances  of  gastric  digestion,  may  have  a  much 
better  effect  afterwards,  since  digestion  has  been 
ameliorated,  because  by  proper  feeding,  judiciously 
carried  out,  the  patient's  general  health  will  be 
greatly  improved. 

Nevertheless  recurrence  of  the  ptosis  is  frequent, 
as  is  made  only  too  evident  from  the  number  of 
procedures  successively  proposed.  Not  one  of  them 
can  be  thoroughly  relied  on,  and  each  operator  has 
his  own  particular  procedure,  which,  however,  does 
not  give  entire  satisfaction. 

It  is  not  our  intention  to  discuss  the  advantages  of 
each  technique  that  has  been  proposed  for  gastro- 
pexy,  but  it  is  to  be  remarked  that  indirect  sutures 
are  being  given  up,  such  as  folding  the  gastrohepatic 
ligament,  and  resort  is  now  more  commonly  had  to 
direct  gastropexia,  that  is  to  say,  those  techniques 
which  fix  the  stomach  to  the  anterior  abdominal 
wall. 


296  SUKGICAL  TEEATMENT 

The  second  objection  to  gastropexy  is  that  this 
operation,  although  it  deals  with  the  ptosis,  has  no 
influence  over  the  gastric  dilatation,  and  without 
which  the  ptosis  would  give  rise  to  no  apparent 
symptoms.  Therefore  to  place  the  stomach  in  its 
normal  position  is  not  enough.  The  dilatation 
occurring  principally  in  the  prepyloric  region,  has 
formed  a  kind  of  cul-de-sac  which  delays  the  gastric 
evacuation  and  by  itself  may  become  a  cause  of 
stasis. 

It  is  for  this  reason  that  to  the  gastropexy  a 
gastrorrhaphy  should  be  added,  which  should,  above 
all,  prevent  the  formation  of  a  prepyloric  cul-de-sac 
whenever  the  gastric  dilatation  is  somewhat  accen- 
tuated. The  stomach  being  thus  put  back  in  place 
and  its  size  reduced,  will  be  able  to  empty  itself ;  and 
therefore,  if  its  walls  are  still  endowed  with  some 
contractile  power,  it  may  be  hoped  that  the  functions 
may  return  to  normal.  One  may  hope ;  one  cannot 
be  certain,  as  is  shown  by  the  great  number  of 
gastropexies,  even  combined  with  gastrorrhaphies, 
where  no  therapeutical  effect  has  been  obtained. 

Gastroenterostomy. — At  first  sight  gastroenteros- 
tomy  might  seem  to  be  especially  indicated  in  cases 
of  gastroptosis.  The  stoma,  placed  at  a  declivous 
part  of  the  stomach,  might  be  supposed  to  empty  the 
organ  regularly  with  ease.  Thus  placed,  it  would, 
in  fact,  seem  as  though  it  could  offer  all  the  desired 
guarantees  for  the  transit  rendered  difficult  by  the 
bend  in  the  first  portion  of  the  duodenum. 

This  was  the  reasoning  of  most  surgeons  when, 
encouraged  by  the  splendid  results  obtained  by  this 


GASTEIC  DYSTOPIAS  297 

operation  in  cases  of  pyloric  stenosis,  they  wished  to 
employ  it  in  all  gastric  affections,  but  before  they 
were  thoroughly  acquainted  with  its  merits  and 
demerits. 

Unfortunately  the  results  obtained  have  not 
satisfied  these  prematurely  founded  hopes.  They 
were  even  far  from  brilliant,  and  the  majority  of 
operators  who  at  first  had  confidence  in  this  treat- 
ment were  not  long  in  renouncing  it.  The  reason  for 
these  failures  is  simple  for  any  one  cognisant  of  the 
physiology  of  this  operation.  The  anastomosis  is 
far  from  assuring  drainage  of  a  cavity  without  any 
inherent  power  of  action  or  motion.  It  will  empty 
a  stomach  when  the  efforts  of  the  organ  are  annihi- 
lated by  an  evident  obstacle,  such  as  stenosis  or 
spasm,  but  it  is  necessary  to  have  more  than  the 
mere  weight  of  food  to  make  the  gastric  contents 
pass  through  the  new  gastric  stoma.  It  is  essential 
that  the  contractions  of  the  muscularis  shall  exercise 
an  intragastric  pressure  of  considerable  strength  in 
order  that  this  shall  take  place,  as  we  have  pointed 
out.  In  gastroptosis  the  obstacle  is  insignificant, 
and  the  stasis  or,  better  still,  the  slow  transit  of  the 
gastric  contents  is,  above  all,  the  result  of  atony  of 
the  organ. 

Therefore,  in  the  great  majority  of  cases,  the 
anastomosis  is  perfectly  useless,  and  in  no  way 
improves  the  evacuation  of  the  stomach.  There 
are,  however,  cases  in  which  ptosis  unquestionably 
predominates,  producing  a  pyloro-duodenal  occlusion, 
although  the  stomach  is  still  capable  of  contracting 
sufficiently  so  that  a  gastroenterostomy  stoma  may 


298  SURGICAL  TREATMENT 

be  of  some  utility.  But  we  would  at  once  add  that 
such  instances  are  rare  and  are  usually  mistaken  for 
pyloric  stenosis  having  secondarily  produced  the 
ptosis.  This  category  of  ptoses  secondary  to  stenosis 
need  not  be  further  considered,  as  they  have  been 
dealt  with  in  another  chapter. 

An  attempt  has  also  been  made  to  improve  the 
results  by  combining  gastrorrhaphy  with  gastro- 
enterostomy.  It  was  hoped  that  by  this  combined 
operation  the  peristaltic  contractions  of  the  stomach 
might  be  facilitated,  but  this  procedure  has  not  given 
any  better  results  than  gastroenterostomy  alone. 

As  a  brief  conclusion  it  may  be  said  that  in  the  vast 
majority  of  cases  medical  treatment  is  the  only 
judicious  one  for  gastroptosis.  Operative  treatment 
should  only  be  resorted  to  when  one  is  convinced 
that  the  gastric  disturbances  depend  upon  a  real 
obstacle  to  the  transit  of  the  gastric  contents,  and 
not  upon  gastric  atony,  as  is  most  frequently  the  case. 
Finally,  unless  the  stomach  has  preserved  sufficient 
contractile  power,  gastroenterostomy  should  be  dis- 
carded and  all  reliance  be  placed  upon  gastropexy, 
with  which  gastrorrhaphy  may  be  combined  with 
advantage. 


CHAPTER  XII 

THE    NERVOUS    DYSPEPSIAS 

BESIDES  the  organic  dyspepsias  resulting  from 
stenosis,  ulcer  or  changes  of  the  position  of  the 
stomach  which  we  have  discussed  in  the  preceding 
pages,  there  is  still  another  very  vast  class  of  dyspep- 
sias having  a  purely  nervous  basis.  This  chapter  is 
unquestionably  one  of  the  most  important  in  gastric 
pathology.  Neglected  for  a  long  time,  the  recent 
work  done  in  this  class  of  cases  has  given  the  subject 
a  foremost  place  among  diseases  of  the  stomach. 
With  Lyon,  the  majority  of  modern  observers  believe 
that  the  greater  number  of  dyspeptics  are  purely 
nervous  subjects.  We  have  referred  to  this  fact 
several  times,  and  we  have  pointed  out  how  prudent 
one  should  be  in  accepting  so  easy  a  diagnosis.  But 
even  allowing  for  much  exaggeration,  invariably 
evident  in  all  new  ideas  and  theories,  we  must  admit 
that  a  nervous  origin  of  gastric  disturbances  is 
certainly  encountered  very  frequently. 

We  cannot  pass  in  review  all  the  manifestations  of 
this  class  of  dyspeptics,  the  symptoms,  pathogenesis 
and  treatment.  We  will  merely  say  that  medical 
treatment,  even  when  properly  carried  out,  is  often 
fruitless,  and  that  all  gastropathies  which  depend 
solely  upon  a  nervous  origin  are  the  longest  and, 
at  the  same  time,  the  most  difficult  to  cure.  It 
is  for  this  reason,  in  face  of  the  numerous  failures  or 
only  partial  success  of  medical  treatment,  that  hope 


300  SUKGICAL  TREATMENT 

has  been  entertained  from  operative  treatment. 
Many  surgeons  have  been  tempted  to  undertake  and 
do  not  shrink  from  resorting  to  surgical  acts,  in  par- 
ticular gastroenterostomy,  hoping  by  this  means  to 
put  an  end  to  the  many  complaints  of  their  patients. 
Let  us  now  examine  the  results  that  have  been 
obtained,  and  then  we  may  be  in  a  position  to  con- 
clude as  to  whether  really  operative  treatment  may 
be  logically  proposed  in  cases  of  nervous  gastro- 
pathies.  If  we  refer  to  the  statistics  of  various 
operators,  we  are  struck  by  the  few  operations  that 
have  been  undertaken  for  this  indication  alone.  On 
the  other  hand,  the  explanation  of  this  fact  is  to  be 
found  in  the  functional  operative  results.  All  observers 
are  unanimous  in  recognising  that  surgical  treatment 
is  devoid  of  usefulness  in  these  cases,  and  this  fact 
has  been  particularly  insisted  upon  by  Mayo-Robson, 
Moynihan,  Moullin,  Hartmann  and  Czerny.  These 
surgeons  have  observed  that  when  the  neuropathic 
element  predominates  operation  is  out  of  the  ques- 
tion, because  it  is  doomed  to  failure,  and  they  even 
recommend,  when  an  organic  gastric  lesion  requires 
surgical  interference,  that  the  operative  acts  should 
not  be  too  long  delayed,  in  order  that  the  organic 
process  may  not  have  sufficient  time  to  exercise  a 
pernicious  influence  over  the  nervous  system.  When, 
from  prolonged  duration  of  the  primary  gastric  lesion, 
the  neuropathic  status  of  the  patient  becomes 
involved,  the  operative  act,  as  we  have  pointed  out, 
is  far  from  giving  as  brilliant  and,  above  all,  as 
rapidly  complete  results  as  those  one  has  the  right 
to  anticipate. 


THE  NERVOUS  DYSPEPSIAS          301 

Therefore  surgical  treatment  should  never  be 
advised  when  one  is  certain  that  the  origin  of  the 
dyspepsia  is  solely  neuropathic ;  and  it  must  be 
admitted  that,  although  medical  treatment  obtains 
but  little  effect,  a  surgical  operation  will  not  result 
in  any  greater  benefit  to  the  patient,  if  even  any 
improvement  whatsoever  results.  On  the  contrary, 
it  is  more  than  likely  that  there  will  be  a  recrudescence 
of  the  symptoms  following  any  surgical  interference. 
But  before  so  frankly  renouncing  surgical  treatment 
all  organic  causes  of  the  dyspepsia  must  be  carefully 
eliminated.  We  have  already  pointed  to  the  danger 
of  accepting  the  diagnosis  of  neuropathy  with  too 
great  ease,  and  we  believe  that  too  much  emphasis 
cannot  be  placed  on  this  point. 

It  is  only  after  a  long  and  conscientious  observa- 
tion of  the  patient  that  a  diagnosis  of  neuropathy 
can  be  arrived  at  in  all  security ;  and,  d  priori, 
operative  treatment  will  be  useless,  even  if  not 
actually  harmful.  Then  in  the  circumstances  the 
somewhat  special  treatments  applicable  to  these 
affections  may  be  resorted  to,  and  should  be  con- 
tinued for  a  necessarily  prolonged  lapse  of  time. 

It  may  nevertheless  be  asked  why  operations 
which  give  unquestionably  such  brilliant  cures,  like 
gastroenterostomy  in  stenosis — even  of  the  inter- 
mittent variety  (spasm) — are  so  powerless  in  neuro- 
pathic dyspepsias,  whose  symptoms  are  in  reality 
often  so  similar.  To  our  way  of  thinking,  failure  in 
operative  treatment  can  be  readily  explained  by  the 
following  reasons  : — 

(1)  The    operation    may   remedy    a    pathological 


302  SURGICAL  TREATMENT 

condition  of  the  stomach,  as,  for  example,  a  per- 
manent or  intermittent  stenosis  ;  this  is  the  most 
evident  and  direct  action  obtained.  In  neuropathic 
dyspepsias  no  pathological  process  of  the  stomach 
exists.  The  stasis  or,  it  were  better  said,  the  slowness 
of  the  pyloric  transit  is  due,  in  the  vast  majority  of 
cases,  to  gastric  atony,  and,  as  we  have  already  said 
when  dealing  with  idiopathic  gastric  dilatation,  opera- 
tive treatment  has  no  action  in  such  cases. 

(2)  Operation  may  have  a  physiological  action  on 
the  secretions  in  particular  ;  it  may  diminish  hyper- 
acidity, but  this  action  is  much  too  indirect  to  make 
itself  felt  on  neuropathic  hypersecretions,  the  aboli- 
tion of  the  stasis  and  duodenal  reflex  being  possible 
only  in  a  more   or   less   complete   stenosis   of   the 
pylorus.    As  to  hyposecretion,  which  is  far  the  most 
common  condition  in  neuropathic  subjects,  operative 
treatment  is  powerless  to  change  it. 

(3)  The  pain  which  accompanies  gastric    neuro- 
pathies is  by  no  means  of  gastric  origin.    It  is  not 
caused  by  an  affection  of  the  stomach  itself,  but  is 
due  to  hyperaesthesia  of  the  solar  plexus,  as  is  made 
evident  by  the  pain  provoked  over  the  epigastric 
point,  and  to  which  so  much  importance  is  at  present 
attributed.     No  operation  on  the  stomach  can  with 
any  degree  of  certainty  exercise  any  influence  over 
this  plexus  ;    therefore  every  operative  act  is  devoid 
of  any  beneficial  influence. 

Consequently  surgical  treatment  is  to  be  reserved 
for  organic  affections,  while  internal  treatment  alone 
should  be  resorted  to  in  neuropathic  affections.  The 
theoretical  conclusions  drawn  from  the  study  of  the 


THE  NERVOUS  DYSPEPSIAS          303 

physiology  of  operative  treatment  already  teach 
this,  while  clinical  experience  proves  it  in  a  sufficiently 
evident  way. 

The  gastric  crises  of  locomotor  ataxia  may  be 
properly  included  among  the  nervous  dyspepsias. 
Several  operators  have  endeavoured  to  remedy  the 
disturbance  by  gastroenterostomy,  but  the  results 
were  so  discouraging  that  the  affection  became 
regarded  as  a  noli  me  tangere.  However,  there  has 
been  some  tendency  in  the  last  fifteen  years  to  return 
to  surgical  treatment,  and  some  little  success  has 
resulted.  It  is  true  that  this  treatment  essentially 
differs  from  that  resorted  to  before. 

After  Foerster  propounded  the  idea  that  division  of 
the  posterior  spinal  nerve  roots  would  overcome  spas- 
modic phenomena  Kuttner  applied  it  to  the  treat- 
ment of  the  gastric  crises  of  locomotor  ataxia.  By 
division  of  the  posterior  nerve  roots  going  to  the 
stomach  the  painful  paroxysms  were  radically  cured. 
Other  surgeons  have  followed  Kiittner's  example,  and 
have  obtained  results  justifying  resort  to  this  opera- 
tion. We  have  performed  it  in  three  cases  success- 
fully, one  patient  having  been  followed  eighteen,  one 
eleven,  and  one  four  months  after  the  operation,  and 
during  these  periods  the  paroxysms  had  not  recurred. 
But  with  the  great  progress  made  during  the  past 
five  years  in  the  specific  medical  treatment  of  neuro- 
syphilis,  and  of  locomotor  ataxia  in  particular,  it  is 
more  than  probable  that  this  operation  will  have 
fewer,  if  any,  indications  in  the  future. 


CHAPTEK  XIII 

DILATATION   OP   THE    STOMACH 

GASTRIC  dilatations  are,  in  a  way,  closely  allied  to 
ptosis,  from  the  fact  that,  as  in  the  latter,  they  may 
be  either  the  consequence  of  an  obstacle  to  the 
evacuation  of  the  stomach  or  a  foremost  manifesta- 
tion of  a  general  affection.  In  point  of  fact,  two  very 
distinct  forms  of  gastric  dilatation  are  generally 
recognised,  namely  : — 

(1)  Mechanical    or    organic    dilatations,    resulting 
from  a  pyloric  or  prepyloric  stenosis. 

(2)  The  so-called  idiopathic  or  atonic  dilatations, 
regarded  by  Mathieu  and  others  as  being  merely  a 
manifestation   of  a   general   pathologic   state,  con- 
genital or  nervous,   and  not  a  special   and  purely 
gastric  affection.    The  first  are  merely  complications 
of  stenosis ;  therefore  only  idiopathic  dilatations  will 
be  considered  here,  as  they  form  a  special  chapter  of 
gastric  pathology. 

The  Causes  of  Idiopathic  Dilatation. — Idiopathic 
dilatation  of  the  stomach  may  in  exceptional  instances 
develop  as  a  local  process.  Soupault  maintains  that 
it  results  from  changes  of  the  general  nutrition  and 
forms  a  part  of  a  symptomatic  complex,  of  which  it 
represents  a  more  or  less  important  element,  but 
without  playing  a  dominating  part,  as  was  formerly 
maintained. 


DILATATION  OF  THE  STOMACH      305 

Considered  from  this  standpoint,  the  dilatation 
cannot  have  any  local  cause  ;  more  remote  causes 
must  be  searched  for  which  are  capable  of  creating  a 
purely  functional  impotency  of  the  gastric  muscu- 
laris.  This  diminution  of  gastric  contractility  may 
be  due  to  various  general  states,  among  which  are  to 
be  noted  : — 

(1)  A  congenital  debility  of  the  muscular  fibres  of 
the  stomach,  as  Bouchardet  and  Le  Gendre  have 
demonstrated.  This  factor  has  certainly  great  import- 
ance, because,  although  when  alone  in  play  it  may 
produce   dilatation,  it  will  usually  be  found   asso- 
ciated with  the  majority  of  other  general  conditions, 
likewise  congenital,  which  play  an  important  part  in 
the  production  of  gastro-intestinal  atony,   and  in 
particular  a  weakness  of  all  the  fibro-muscular  struc- 
tures of  the  body.     Thus  in  gastric  dilatation  the 
subject   will  often  present   ptoses,   gastroptosis   or 
splanchnoptosis,  intestinal  atony,  and  a  particular 
tendency  to  hernia,  venous  ectasis,  etc. 

(2)  Besides    this    congenital    predisposition    that 
certain  observers  regard  as  indispensable,  consider- 
able importance  should  be  attributed  to  all  causes 
depressing  the  nervous  system.    Thus  neurasthenia, 
the  various  neuropathies  and  overwork,  both  physical 
and  mental,  must  be  regarded  as  debilitating  in  the 
same  way  as  chlorosis,  tuberculosis  and  typhoid  fever 
are,  and  are  just  so  many  causes  for  gastric  dilatation. 
But  in  order  that  this  shall  take  place  it  is  necessary 
for  these  morbid  processes  to  develop  in  a  predis- 
posed soil.    This  is  a  primordial  condition  that  the 
majority  of  writers  now  place  in  the  foremost  rank. 


306  SUEGICAL  TEEATMENT 

Indications  for  Surgical  Treatment. — The  patho- 
genic concept  of  idiopathic  dilatation  which  recognises 
the  capital  importance  of  a  congenital  predisposition, 
often  aggravated  by  an  acquired  general  affection, 
throws  an  entirely  new  light  on  the  therapeutical 
indications.  Gastric  dilatation  is  an  affection 
which  should  be  treated  by  general  therapeutical 
measures. 

It  may,  however,  be  asked  if  in  the  treatment  of 
its  consequences  there  is  not  some  advantage  to  be 
derived  from  surgical  treatment.  What  are  the  dis- 
turbances resulting  from  dilatation  if  they  are  not 
the  phenomena  of  stasis  or,  more  exactly  put,  a  slow 
evacuation  of  the  stomach  ?  If  this  slow  transit  of 
the  ingested  food  provokes  such  serious  disturbances, 
should  not  an  attempt  be  made  to  overcome  it  and 
accelerate  the  emptying  of  the  gastric  contents  ? 
Internal  medication  being  so  slow  and  uncertain  in 
its  results,  should  not  a  large  stoma  through  which 
the  gastric  contents  can  flow  off  rapidly  and  with 
greater  ease  be  made  ?  Before  replying  to  these  ques- 
tions we  must  ascertain  why  and  how  the  stomach 
empties  itself  poorly  and  in  what  way  an  operation 
might  ameliorate  this  evacuation. 

If  the  stomach  has  so  much  difficulty  in  getting  rid 
of  its  contents,  it  is  not  because  there  is  an  obstacle 
in  the  way,  but  because  of  its  weak  contractile  power. 
Lacking  in  tonus,  its  walls  allow  themselves  to 
become  distended  beyond  the  normal  limits.  The 
gastric  walls  are  weak  and  paretic  throughout  their 
entire  extent,  as  much  in  the  region  of  the  cardia  as 
in  the  immediate  neighbourhood  of  the  pylorus.  The 


DILATATION  OF   THE   STOMACH      307 

pylorus  itself  is  involved  in  the  general  weakness,  and 
does  not  contract ;  on  the  contrary,  it  remains  largely 
patent,  offering  no  resistance  to  the  passage  of  the 
gastric  contents.  Consequently  in  reality  there  is  no 
mechanical  obstacle — stenosis,  bend,  etc. — nor  a 
physiological  barrier — spasm.  The  only  cause  of 
the  slow  motility  is  clearly  the  lack  of  contractility 
of  the  stomach  walls. 

What  would  be  the  part  played  by  a  new  stoma 
resulting  from  a  gastroenterostomy  ?  Let  us  say  at 
once  that  any  supposed  benefit  to  be  derived  is 
superlatively  illusive.  No  matter  how  large  the 
stoma,  a  gastroenterostomy  cannot  produce  a  better 
evacuation  of  the  stomach  than  that  already  assured 
by  a  normal  pylorus,  that  is  to  say,  one  without 
stenosis.  Furthermore,  we  have  already  stated  what 
part  is  played  by  a  gastroenterostomy  stoma  in 
cases  of  patent  pylorus  ;  it  is  nil,  and  it  can  never 
be  supposed  to  fulfil  the  functions  of  a  drainage  open- 
ing, even  when  it  is  located  on  a  declivous  part  of 
the  stomach. 

The  knowledge  possessed  to-day  derived  from  the 
data  acquired  from  the  physiology  of  gastroenteros- 
tomy has  been  amply  demonstrated  clinically  by  the 
experience  of  those  less  informed  operators  who  at 
the  beginning  of  the  era  of  gastric  surgery  founded 
their  hopes  on  the  operative  treatment  of  idiopathic 
gastric  dilatation.  Their  disillusion  was  soon  forth- 
coming. The  results  obtained  were  deplorable  ;  in 
the  majority  of  cases  there  was  no  amelioration,  and 
in  many  the  gastric  condition  was  made  distinctly 
worse.  Therefore,  as  in  the  case  of  gastroptosis,  the 


308  SUEGICAL  TKEATMENT 

operative  indications  in  dilatation  are  extremely 
limited. 

Consequently  it  can  be  said  that  atonic  dilatation 
of  the  stomach  is  a  strictly  medical  affection  and 
interests  the  surgeon  only  from  the  warning  not  to 
interfere  in  these  cases. 

Although  we  have  been  so  affirmative  in  recog- 
nising the  utter  uselessness  of  an  operation,  we  would 
remark  that  we  have  only  been  considering  those 
cases  in  which  the  diagnosis  of  the  gastric  condition 
has  been  certain  and  lends  itself  to  no  discussion. 
We  have,  so  to  speak,  maintained  a  theoretical  view- 
point, because  in  practice  the  distinction  between 
dilatation  from  an  obstacle  and  that  resulting  from 
pure  atony  is  often  a  very  delicate  matter  to  decide. 
Such  a  differential  diagnosis  is,  however,  of  utmost 
importance,  because  the  latter  process  is  a  surgical 
noli  me  tcmgere,  while  the  former  is  entirely  a 
surgical  proposition. 

In  practice  it  is  infinitely  more  simple  to  admit  a 
diagnosis  of  atonic  dilatation  ;  but  is  this  really  a 
diagnosis,  and  is  it  not  more  frequently  the  mere 
verification  of  a  symptom  whose  cause  has  not  been 
ascertained  ?  How  often  do  we  meet  with  cases  of 
so-called  atonic  gastric  dilatation,  the  result  of  some 
neuropathy  or  overwork,  which  when  conscientiously 
examined  are  found  to  be  due  to  a  long-standing 
fibrous  stenosis  having  profoundly  reacted  upon  the 
gastric  functions  in  general !  How  many  do  we  not 
see  that  suddenly  end  in  perforation  of  a  pyloric  or 
duodenal  ulcer  ! 

The  conclusion  is  that  one  should  not  be  content 


DILATATION   OF  THE  STOMACH      309 

with  the  diagnosis  of  atonic  dilatation  only  when  a 
searching  examination  and  minute  observation  have 
permitted  the  surgeon  to  discard  with  certainty  the 
existence  of  an  organic  barrier.  It  is  only  in  these 
circumstances  that  medical  treatment  is  permissible. 

There  are,  however,  cases  in  which  medical  treat- 
ment remains  ineffectual,  where  in  particular  the 
gastric  disturbances  have  not  been  improved, 
although  the  general  physical  condition  may  have 
been  considerably  ameliorated.  These  are  cases  in 
which  dilatation  is  so  developed  that  it  forms  a 
pyloric  pocket  constituting  a  true  cul-de-sac.  A 
mechanical  obstacle  is  thus  created  that  the  gastric 
walls  will  have  difficulty  in  overcoming,  even  when 
they  have  regained  their  tonicity.  In  the  circum- 
stances surgical  treatment  may  give  good  results. 
These  circumstances  are  rare,  very  rare  even,  and 
surgical  interference  must  be  reserved  for  these 
exceptional  cases  only. 

In  this  case  the  obstacle  is  not  at  the  pylorus  ;  it 
is  to  be  found  only  in  the  formation  of  the  cul-de-sac  ; 
therefore  the  treatment  should  be  directed  against  the 
latter  condition,  and  the  procedure  to  be  selected  will 
be  gastroplication,  which  seems  to  give  better  results 
than  gastroenterostomy  or  even  gastroduodenostomy, 
which  would  seem  particularly  indicated  in  these 
cases. 


CHAPTER  XIV 

TUBERCULOSIS    AND    SYPHILIS    OP    THE    STOMACH 

BOTH  these  infections  may  produce  gastric  lesions 
of  very  varied  types.  For  a  long  time  regarded  as 
rarities,  such  lesions  are  becoming  more  frequently 
encountered,  since,  being  better  known,  they  are 
searched  for  with  more  care.  Interesting  from  the 
view-point  of  diagnosis,  they  are  far  less  so  from  the 
view-point  of  treatment,  at  least  as  far  as  surgery  is 
concerned. 

According  to  the  recent  statistics  published  by 
Simonds,  based  upon  a  total  of  2,000  autopsies  on 
tuberculous  subjects,  the  frequency  of  tuberculous 
gastric  ulcer  is  four  per  1,000,  while  according  to 
Arloing  and  Batsere  it  is  from  six  to  seven  per  1,000. 
The  ulcer  is  usually  seated  in  the  lesser  juxtapyloric 
cul-de-sac,  but  it  may  be  met  with  on  the  greater 
curvature,  the  posterior  gastric  wall,  lesser  curvature, 
anterior  gastric  wall  and  the  greater  cul-de-sac. 
The  ulcer  is  sometimes  multiple,  as  many  as  three  or 
four  having  been  found,  but  rarely  more ;  excep- 
tionally they  may  be  very  numerous,  as  in  Hamilton's 
case,  in  which  there  were  120. 

The  aspect  of  a  tuberculous  ulcer  varies.  Some- 
times the  edges  are  thick,  elevated  and  clean-cut ; 
at  others  the  edges  are  thin.  The  surrounding 
mucosa  will  usually  present  small  miliary  granula- 
tions. The  tuberculous  process  sometimes  under- 


TUBERCULOSIS  OF  THE  STOMACH  811 

mines  the  ambient  submucosa,  so  that  a  large,  deep 
ulcer  may  open  at  the  surface  by  only  a  minute 
aperture. 

Tuberculous  gastric  ulcers  are  irregular,  stellate 
or  oval  in  outline,  while  in  some  instances  they  affect 
the  form  of  a  fissure.  The  fundus  is  usually  yellow 
or  greyish  red  with  a  caseous  aspect.  Occasionally 
sinuses  dip  deeply  down  into  the  walls  of  the  stomach. 
The  peritoneum  is  often  covered  by  a  fibrinous 
exudate  and  miliary  tubercles.  Adhesions  may 
develop,  and  perforation  takes  place  either  into  the 
peritoneal  cavity  or  into  an  adherent  coil  of  intestine, 
resulting  in  a  gastro-intestinal  sinus.  In  most  cases 
the  perigastric  lymph  nodes  offer  tuberculous  changes 
of  varying  degrees. 

Males  are  more  frequently  afflicted  with  tuberculous 
gastric  ulcer  than  females.  The  process  is  especially 
frequent  between  the  ages  of  thirty-five  and  forty 
years,  but  it  may  arise  in  elderly  subjects.  The  lesion 
is  apt  to  be  overlooked  clinically,  but  when  it  gives 
rise  to  symptoms  these  offer  no  distinctive  characters 
and  are  usually  attributed  to  the  terminal  gastritis  of 
phthisis  or  the  indefinite  signs  of  abdominal  tuber- 
culosis presented  by  the  majority  of  tuberculous 
subjects.  Even  the  complications,  sometimes  of  a 
most  serious  nature,  such  as  haematemesis  or 
perforation,  are  not  characteristic,  because  an 
ordinary  peptic  ulcer  may  perfectly  well  develop  in 
tuberculous  subjects.  The  only  means  at  our  dis- 
posal for  making  a  diagnosis  of  tuberculous  ulcer  of 
the  stomach  with  any  degree  of  probability  is  the 
presence  of  lesions  of  tuberculosis  in  the  lungs. 


312  SURGICAL  TREATMENT 

The  prognosis  and  duration  of  the  ulcer  are  prac- 
tically unknown,  because  the  prognosis,  other  than 
for  some  cases  of  death  from  gastrorrhagia  or  perfora- 
tion, above  all  depends  upon  the  pulmonary  lesions. 
The  tuberculous  ulcer  just  described  is  not  the 
only  bacillary  lesion  encountered  in  the  stomach. 
A  chronic  form  of  gastric  tuberculosis  exists,  and  is 
described  by  most  observers  as  stenosing  tuberculosis 
of  the  stomach,  which,  from  the  view-point  of  patho- 
logy, would  seem  to  correspond  with  the  so-called 
hyperplastic  or  hypertrophic  tuberculosis  met  with 
in  the  caecum. 

The  ulcer,  which  is  usually  close  to  the  pylorus,  is 
at  times  small  and  superficial,  or  it  may  be  very  exten- 
sive and  deep  ;  it  may  also  assume  the  annular  type 
of  lesion.  The  fundus  of  the  ulcer  is  either  sanious 
or  covered  with  granulation  tissue  ;  the  adjacent 
gastric  wall  is  indurated,  thickened  and  infiltrated, 
the  pylorus  is  stenosed,  and  the  duodenum  may  even 
be  involved  in  the  process.  Mathieu  and  Remond 
have  found  Koch's  bacillus  in  the  lesions.  In  the 
majority  of  cases  the  regional  lymph  nodes  are 
caseous. 

Stenosing  tuberculosis  of  the  pylorus — at  least  in 
some  cases — appears  to  be  a  primary  lesion,  and  in 
some  recent  statistics  the  presence  of  tuberculous 
lesions  in  the  lungs  was  only  found  in  about  45  per 
cent,  of  the  cases. 

The  surgical  treatment  of  tuberculous  gastric 
lesions  will  rarely  be  indicated,  especially  on  account 
of  the  precarious  condition  of  the  patient's  general 
health.  When  the  ulcer  has  not  produced  stenosis 


TUBERCULOSIS  OF  THE  STOMACH  818 

the  only  surgical  treatment  to  be  advised  is  excision, 
which  means  a  particularly  laborious  and  delicate 
operation,  usually  far  too  serious  to  be  supported  by 
patients  of  this  class. 

Pyloric  stenosis  of  tuberculous  origin  is  a  very 
serious  affection,  with  a  darker  prognosis  than  that 
of    carcinoma    (Tuffier).     The    medical    treatment, 
which  is  perfectly  useless  in  so  far  as  recovery  is 
concerned,   should   be   discarded  in  every  case  in 
which  the  patient's  general  physical  condition  will 
permit  the  physician  to  conscientiously  turn  the  case 
over   to   the   surgeon.     The   operation    may   be   a 
palliative  one,  consisting  in  gastroenterostomy,  which 
has  never  prolonged  life  for  more  than  two  years,  or  a 
radical   interference   consisting   in    a   pylorectomy, 
which  is  invariably  serious  and  delicate  to  carry  out. 
Consequently  tuberculous  processes  of  the  stomach 
are   unquestionably   grave  ;    they  certainly  are  in- 
teresting from  the  surgical  view-point,  but  it  should 
be  distinctly  understood  that  operative  treatment 
will  never  give  brilliant  results.     A  laborious  inter- 
ference is  always  to  be  anticipated,  and  therefore  the 
prognosis  offers  little  encouragement. 

As  to  syphilitic  gastric  lesions,  they  likewise  consist 
in  ulcers  and  pyloric  stenosis,  to  mention  only  the  more 
common  lesions  due  to  luetic  infection.  Aaron  states 
that  about  one  out  of  every  seventy-five  gastric  cases  is 
syphilitic  and  that  all  instances  so  far  observed  have 
occurred  during  the  tertiary  phase  of  the  infection. 

The  diagnostic  errors  to  which  patients  with 
syphilis  of  the  digestive  tract  are  exposed  are  legion, 
the  majority  of  these  affections  being  regarded  as 


314  SURGICAL  TREATMENT 

local  processes  or  as  having  a  nervous  origin.  Gastric 
syphilis  in  the  form  of  ulcer  or  cancer  is  the  origin 
of  frequent  mistakes.  Fournier  and  Dieulafoy  long 
ago  recognised  the  fact  that  gastric  ulcer  was  occa- 
sionally the  result  of  syphilis,  and  we  would  add  that 
it  is  in  all  probability  a  frequent  etiological  factor. 
This  likewise  applies,  we  believe,  to  duodenal  ulcer. 
Between  a  syphilitic  gastric  ulcer  and  an  ulcer  of 
indeterminate  etiology  there  is  no  differential  clinical 
sign. 

Galliard  long  since  insisted  upon  the  relationship 
of  gastric  nicer  and  syphilis,  and  referred  to  Engel's 
figures — which  he  regarded  as  somewhat  high — 
which  revealed  the  existence  of  syphilis  in  10  per 
cent,  of  the  cases,  and  Lang,  who  believed  it  to  be 
the  etiological  factor  in  20  per  cent,  of  the  cases. 
These  and  other  data  do  not  seem  to  prevent 
surgeons  from  operating  on  gastric  or  duodenal  ulcer 
without  taking  the  trouble  to  have  a  Wassermann 
made  or  to  resort  to  a  test  treatment.  It  is  really 
curious  still  to  read  articles  on  this  subject  in  which 
the  word  "  syphilis  "  is  not  even  mentioned. 

Two  cases  of  death,  recorded  respectively  by 
Jacquet  and  Selenow,  following  injections  of  arseno- 
benzol,  were  due  to  an  acute  reaction  arising  in  the 
walls  of  unrecognised  syphilitic  gastric  ulcers ;  and 
Leredde  states  that  he  has  recently  seen  a  case  of 
duodenal  ulcer  that  was  to  be  operated  on  recover 
after  three  injections  of  novarsenobenzol,  so  that 
the  operation  became  unnecessary.  We  have  per- 
sonally had  three  cases  of  gastric  ulcer  symptoma- 
tically  cured  by  specific  treatment.  Two  of  these 


patients  gave  a  history  of  previous  syphilitic  infec- 
tion ;  the  third  patient  presented  a  tertiary  syphilitic 
process  on  the  skin  at  the  time  he  came  under 
observation  for  the  gastric  symptoms. 

Strictly  speaking,  there  is  no  surgical  treatment  for 
gastric  syphilis,  any  more  than  for  other  manifesta- 
tions of  this  infection.  Nevertheless  a  certain 
number  of  operations  for  pyloric  stenosis  of  syphilitic 
origin  have  been  done,  particularly  pylorectomy, 
which  have  resulted  in  histologically  demonstrating 
the  true  nature  of  the  neoplasms  causing  the  stenosis. 
Therefore  in  pyloric  stenosis  it  should  never  be 
forgotten  that  some  cases  are  suitable  for  specific 
treatment,  and  this  should  be  instituted  in  every 
instance  where  other  syphilitic  manifestations  exist 
or  where  a  history  of  syphilitic  infection  is  obtained 
when  the  patient's  general  condition  permits  a 
prolonged  observation.  By  so  doing  one  may  be 
fortunate  enough  to  cause  the  pyloric  tumour  and 
stenosis  to  disappear  without  submitting  the  patient 
to  operation,  although  we  would  add  that  such  a 
fortunate  outcome  is  rarely  observed  in  practice. 


CHAPTER  XV 

DISTURBANCES   OF   SECRETION 

AT  the  present  time  the  same  importance  cannot 
be  attributed  to  disturbances  of  the  gastric  secretion, 
as  was  the  case  a  few  years  ago.  Changes  in  the 
gastric  chemism  are  so  frequent,  and  are  so  little 
related  to  any  well-defined  affection  of  the  stomach, 
that  the  value  of  the  data  obtained  by  test  meals  has 
been  doubted  by  many  competent  observers. 

The  gastric  secretions,  and  hydrochloric  acid  in 
particular,  may  offer  considerable  variations  in  the 
same  patient  without  giving  rise  to  any  apparent 
symptom.  Consequently  it  is  to  be  inferred  that, 
taken  by  itself,  an  increase  or  diminution  of  the 
hydrochloric  acid  cannot  result  in  any  pathological 
entity.  Nevertheless  certain  affections  present  a 
characteristic  symptomatic  picture  whose  most  evi- 
dent feature  is  certainly  that  of  disturbances  of  the 
secretions.  There  is  clearly  a  close  relationship 
between  the  modality  of  gastric  chemism  and  the 
affection,  of  which  it  is  more  one  of  the  symptoms 
than  the  cause,  as  was  formerly,  and  for  a  long  time, 
maintained. 

We  cannot  enter  into  the  details  of  gastric 
chemism,  as  this  would  extend  beyond  the  domain 
of  this  book.  Therefore  we  will  study  the  two 
largest  classes  of  disturbances  of  gastric  secretion, 


DISTURBANCES  OF  SECRETION       317 

the  only  ones  really  interesting  to  the  surgeon. 
These  two  classes  of  changes  of  the  gastric  chemism 
are  : — 

(1)  Simple    hyperchlorhydria,     or     Reichmann's 
disease. 

(2)  Hypochlorhydria. 

Simple  hyperchlorhydria  is  encountered  in  a 
number  of  gastric  diseases,  as  certain  nervous 
dyspepsias  and  ulcers  in  particular,  it  being  one  of 
the  most  important  symptoms  of  the  latter  process. 
It  is,  therefore,  far  from  being  an  entity,  and  for  this 
reason  offers  little  interest.  Its  treatment  in  most 
instances  will  be  strictly  medical ;  in  others,  espe- 
cially ulcer,  we  have  already  stated  what  may  be 
expected  from  surgical  treatment. 

As  to  hyperchlorhydria,  which  is  the  fundamental 
symptom  of  a  special  morbid  process  to  which 
Reichmann  has  given  his  name,  it,  on  the  contrary, 
offers  considerable  interest  for  the  surgeon,  not 
simply  because  of  its  treatment,  but  also  on  account 
of  its  pathogenesis. 

Is  Reichmann's  disease  in  reality  a  morbid  entity  ? 
This  is  the  first  problem  to  be  solved.  Many  compe- 
tent observers,  like  Mathieu,  Roux  and  Debove,  do 
not  admit  that  it  is,  while,  if  one  especially  studies 
the  causes  of  this  disease,  it  will  be  found  that  even 
those  who  elevate  the  syndrome  of  pyloric  spasm 
with  hyperchlorhydria  to  this  rank  include  under 
this  heading  an  infinite  number  of  cases  which  offer 
nothing  characteristic. 

In  this  respect  the  profession  is  far  from  being  of 
the  same  mind  as  to  the  causes  of  Reichmann's 


318  SURGICAL  TREATMENT 

disease.  Numerous  and  contradictory  as  are  the 
pathogenic  theories  propounded,  still  it  is  essential  to 
be  cognisant  of  them  in  order  to  carry  out  a  really 
effective  treatment.  For  Reichmann  himself  the 
affection  is  characterised  by  hyperchlorhydria  or, 
better  still,  a  continuous  hy persecution,  perhaps 
accompanied  by  stenosis.  According  to  Bouveret 
and  Devic,  there  are  two  forms  of  Reichmann's 
disease  ;  one,  essentially  nervous  in  origin,  may  even 
accompany  organic  affections,  like  certain  gastric 
crises  of  locomotor  ataxia,  the  other  consisting  of 
a  hypersecretion  following  ulcer  of  the  stomach. 
Hayem,  who  has  studied  this  affection  with  great 
care,  believes  that  it  is  invariably  the  result  of  a 
stenosis. 

In  reality  for  many  observers  hyperchlorhydria 
and  hypersecretion  are  the  result  of  a  pyloric  stenosis, 
be  it  either  permanent  or  transitory,  like  a  spasm,  as 
the  researches  by  Doyen,  Carle  and  Fantino  seem  to 
prove.  We  have  already  remarked  how  often 
retention,  even  when  not  pronounced,  especially  at 
its  onset,  will  provoke  hypersecretion,  followed  later 
on  by  pain,  that  are  found  in  Soupault's  pyloric 
syndrome  and  Robin's  symptomatology  of  gastric 
hypersthenia.  Both  these  groups  of  symptoms  are 
similar  to  those  met  with  in  Reichmann's  disease. 

J.  C.  Roux  and  others  maintain,  on  the  contrary, 
that  the  hyperchlorhydria  is  the  first  to  appear, 
and  then  engenders  spasm.  But,  whatever  theory  be 
accepted,  one  does  not  always  know  what  produces 
the  spasm  or  what  causes  the  exaggerated  secretion. 
In  many  instances  one  has  relied  as  a  basis  upon 


DISTURBANCES  OF  SECRETION       319 

the  observations  made  by  surgeons  who,  operating  on 
cases  of  Reichmann's  disease,  have  been  unable  to 
discover  any  gastric  lesion  which  might  account  for 
the  symptomatic  phenomena  observed.  Now  it  is 
known  that  the  spasm  may  be  caused  by  a  minute 
ulcer  of  the  mucosa,  seated  in  the  prepyloric  area,  a 
lesion  that  it  is  impossible  to  detect,  and  that,  on 
the  other  hand,  a  lesion  distant  even  from  the  pylorus 
may  be  the  starting-point  of  secretory  reflexes  of 
the  glands  of  the  entire  stomach,  and  especially  of 
acid  secretion. 

Moynihan  admits  that  permanent  hyperchlorhy- 
dria,  acid  gastritides,  etc.,  usually  accompanied  by 
late-appearing  pain,  are  not  certain  diagnostic 
elements  for  duodenal  ulcer.  Therefore  we  believe 
that  great  reserve  should  be  maintained  in  respect 
to  the  diagnosis  of  Reichmann's  disease  taken  in  the 
strict  sense  of  the  term,  and  that,  if  the  cases  published 
under  this  name  be  carefully  examined,  it  will  be 
found  that  the  majority  of  them  are  simply  instances 
of  particularly  tenacious  ulcers  in  full  activity,  from 
the  very  fact  that  they  simultaneously  provoke 
spasm  and  hyperchlorhydria.  Otherwise  put,  the 
symptoms  of  the  really  primary  process  are  entirely 
overlooked,  hidden  as  they  are  by  direct  conse- 
quences. 

This  understanding  of  Reichmann's  disease  brings 
it  back  to  the  rank  of  a  syndrome  which  unquestion- 
ably has  its  importance  and  a  value  from  the  view- 
point of  treatment,  because  it  invariably  implies 
the  notion  of  a  combination  of  stenosis  and  hyper- 
secretion.  Of  these  two  consequences  of  the  initial 


320  SURGICAL  TREATMENT 

lesion  it  is  of  small  import  to  know  which  one 
favoured  the  development  of  the  other,  the  primordial 
cause  being  the  one  to  be  treated.  By  directing  the 
treatment  against  it  it  may  be  hoped  that  at  the 
same  time  as  it  is  relieved  the  symptoms  of  stenosis 
and  those  resulting  from  hyperchlorhydria  will  dis- 
appear as  well. 

But,  as  we  have  pointed  out,  the  stenosis  presents 
two  very  different  types.  It  is  either  due  to  a  spasm 
— therefore  transitory  and  modifiable  from  the 
evolution  of  the  initial  lesion — or  it  is  a  more  or  less 
well-developed  organic  stricture  over  which  the 
evolution  of  the  primordial  affection  will  have  no 
influence  whatsoever. 

Of  the  total  number  of  operations  undertaken  for 
the  cure  of  Reichmann's  disease  we  find  there  are 
two  classes,  differentiated  by  the  fact  that  in  one 
gastric  aspiration  on  an  empty  stomach  only  with- 
draws pure  gastric  juice,  while  in  the  other  the 
gastric  secretion  is  mixed  with  some  food.  In  the 
first  class  the  stasis  is  clearly  transitory  and  mild, 
and  these  are  the  cases  in  which  the  stenosis  has  a 
purely  spasmodic  origin  ;  in  the  second  class  the 
more  pronounced  stasis  indicates  a  more  permanent 
stenosis,  probably  cicatricial  in  nature,  although  the 
existence  of  a  superadded  spasm  cannot  be  ruled 
out. 

Even  besides  these  cases,  which,  all  things  con- 
sidered, are  merely  a  special  form  of  ulcer  or  even 
pyloric  stenosis,  we  must  unquestionably  admit  the 
possibility  of  a  hypersecretion  with  spasm  having  a 
purely  nervous  origin.  Such  instances  represent 


DISTURBANCES  OF  SECRETION       321 

the  true  causes  of  Reichmann's  disease,  and  they  are 
by  far  the  most  infrequent.  We  should  therefore, 
when  speaking  of  the  indications  for  operation  in  this 
affection,  not  refer  strictly  to  these  absolutely  pure 
types  of  the  disease,  but  should  include  those  which 
in  practice  are  still  regarded  as  Reichmann's  disease. 
The  similarity  of  their  characters  and  symptoms 
prevents  making  a  distinction  from  the  clinical 
standpoint. 

Operative  Indications. — The  treatment  of  Reich- 
mann's disease,  like  that  of  simple  peptic  ulcer,  is  in 
principle  strictly  medical,  but,  as  in  gastric  ulcer, 
this  treatment  is  not  invariably  efficient,  and  there 
are  circumstances  which  oblige  one  to  resort  to  more 
energetic  therapeutical  measures,  such  as  a  surgical 
interference.  We  have  shown  that  in  this  group  a 
number  of  various  affections  characterised  by  acid 
hypersecretion  with  phenomena  of  pyloric  spasm 
have  been  comprised.  The  combination  of  these 
two  symptoms  results  in  a  particularly  stubborn 
character  of  the  affection,  and  explains  why  it  so 
frequently  resists  medical  treatment. 

On  the  other  hand,  we  have  shown,  when  speaking 
of  ulcer,  how  effective  surgical  interference  is  in 
overcoming  both  spasm  and  hyperchlorhydria ; 
and  in  respect  to  Reichmann's  disease  operative 
treatment  is  usually  successful,  and  gastric  surgery 
has  here  even  attained  its  most  brilliant  results. 

But  should  operation  be  advised  in  every  case  of 
gastric  hypersecretion  with  spasm  ?  We  believe 
that  this  would  be  somewhat  useless.  Many  patients 
easily  recover  by  simple  medical  treatment,  and  it 

s.i.  y 


322  SUEGICAL  TREATMENT 

should  be  a  rule  to  try  this  treatment  at  least  for 
a  sufficient  length  of  time  to  allow  it  to  act.  Other- 
wise put,  the  same  rule  applies  here  as  for  cases  of 
gastric  ulcer.  If,  after  medical  treatment  regularly 
followed  for  one  month  to  six  weeks,  no  amelioration 
occurs,  surgical  treatment  should  be  resorted  to 
without  further  delay.  The  majority  of  observers 
have,  we  believe,  adopted  this  principle,  but  certain 
circumstances  should  require  an  immediate  operation. 

Such  is  the  case  when  the  subject  is  seriously  ill 
from  the  disease,  which  has  lasted  for  some  time,  as 
medical  treatment  will  be  of  little  avail.  To  continue 
it  for  any  length  of  time  will  not  only  be  losing  much 
precious  time,  but  will  seriously  compromise  the 
results  of  the  surgical  act  that  one  will  finally  be 
obliged  to  propose.  Therefore  it  is  essential  to  know 
how  to  differentiate  from  the  onset  those  cases  which 
will  benefit  by  medical  treatment  from  those 
rebellious  to  it.  Such  a  distinction  is  not  always 
possible ;  certain  circumstances  should  nevertheless 
offer  useful  indications. 

As  Delangre  has  remarked,  many  observers  con- 
sider that  when  Eeichmann's  disease  is  characterised 
by  continued  hypersecretion,  revealed  by  aspiration 
on  an  empty  stomach,  the  gastric  content  being  pure 
gastric  juice,  medical  treatment  will  usually  give  good 
results. 

When,  on  the  contrary,  aspiration  on  an  empty 
stomach  withdraws  gastric  juice  mixed  with  food 
ingested  the  evening  before,  thus  indicating  a  more 
or  less  advanced  degree  of  stasis,  it  is  generally 
admitted  that  operation  may  be  efficacious,  and  that 


DISTURBANCES  OF  SECRETION       323 

an  attempt  with  medical  treatment  is  perfectly 
useless. 

This  way  of  setting  forth  the  operative  indication 
in  Reichmann's  disease  appears  to  us  to  be  perfectly 
justified,  and  seems  to  be  a  sure  and  practical  rule 
to  follow  in  practice.  We  would,  however,  point  out 
that  cases  of  Reichmann's  disease  accompanied  by 
permanent  stasis,  detected  by  the  nature  of  the 
gastric  contents  withdrawn  in  the  morning  while 
fasting,  are  not  pure  cases  of  the  affection  in  the 
strict  sense  of  the  term.  They  would  be  more 
correctly  placed  under  the  heading  of  pyloric  stenosis, 
whose  only  treatment  is  surgical.  If  we  refer  to 
them  here,  it  is  because  a  number  of  observers  do  not 
make  this  distinction  and  qualify  by  the  name  of 
Reichmann's  disease  all  cases  in  which  hypersecretion 
predominates,  while  the  other  phenomena  of  stasis 
are,  on  the  contrary,  not  very  evident. 

To  be  brief,  we  would  say  the  pure  Reichmann's 
disease  should  be  treated  medically,  while  surgical 
interference  is  only  to  be  proposed  when — (1)  medical 
treatment  has  proved  to  be  ineffective  ;  (2)  the  long 
duration  of  the  process  has  profoundly  affected  the 
patient's  health,  and  it  has  become  urgent  to  restore 
the  physical  condition  without  delay  ;  (3)  besides 
the  usual  symptoms  of  the  affection,  signs  of  gastric 
stasis,  even  of  a  mild  degree,  become  superadded. 

What  results  are  to  be  expected  from  operative 
treatment  ?  Are  they  sufficiently  good  to  have  the 
patient  assume  the  risk — although,  in  truth,  very 
trifling — of  an  abdominal  operation  ? 

Those  who  have  so  far  written  on  the  subject  are 

T  2 


824  SURGICAL  TREATMENT 

not  sufficiently  agreed  on  the  nature  of  Reichmann's 
disease,  so  that  it  is  impossible  to  find  any  really 
conclusive  statistics  in  the  literature.  The  various 
cases  which  for  some  are  to  be  considered  as  belong- 
ing to  this  affection  are  by  others  classified  under  the 
head  of  stenoses  or  even  hypersthenic  dyspepsias, 
hence  rendering  those  researches  in  this  direction 
most  uncertain.  Therefore  we  are  disinclined  to 
present  figures  which  could  only  have  a  very  relative 
value,  but  what  we  are  prepared  to  affirm  from  our 
own  experience  is  that  operative  interference  in 
Reichmann's  disease  gives  the  best  results  and  the 
largest  number  of  successful  outcomes  of  any  opera- 
tion in  the  domain  of  gastric  surgery,  and  we  are  also 
inclined  to  believe  that  this  is  the  general  consensus  of 
opinion  of  those  who  have  had  experience  in  the  matter. 

Theoretically  such  constant  success  should  be 
anticipated,  because  surgical  treatment  is  sovereign 
in  pyloric  stenosis,  particularly  in  cases  accompanied 
by  a  hypersthenic  condition  of  the  stomach,  and  it  is 
just  these  very  conditions  that  are  found  united  in 
Reichmann's  disease. 

The  Choice  of  the  Operative  Procedure. — It  is 
hardly  necessary  to  discuss  the  comparative  advan- 
tages of  the  different  gastric  operations.  At  the 
present  time  there  is  only  one  that  should  be  resorted 
to,  because  it  fulfils  all  the  indications  required  by 
the  affection  under  consideration.  In  reality  two 
factors  have  to  be  dealt  with,  namely,  gastric  reten- 
tion and  hyperchlorhydria,  and  the  only  operation 
that  can  and  does  relieve  the  semorbid  states  is 
gastroenterostomy.  As  we  have  discussed  its  physio- 


DISTURBANCES  OF  SECRETION       325 

logical  action  at  length,  we  need  not  refer  to  it  here. 
Suffice  it  to  say  that  Katzenstein's  experiments 
have  shown  the  direct  influence  that  this  operation 
exercises  over  the  gastric  secretions. 

Not  many  years  ago  the  surgeon  might  well 
hesitate  between  gastroenterostomy  and  Mikulicz's 
pyloroplasty  and,  still  more  remotely,  Loretta's 
divulsion  of  the  pylorus,  but  at  present  experience 
has  demonstrated  the  incompleteness  of  the  two 
later  procedures,  and  they  are  not  mentioned  in 
recent  statistics.  As  to  excision  of  the  pylorus, 
it  can  offer  no  evident  advantage,  and  although  it 
presents  itself  under  favourable  auspices  in  cases  of 
spasm  without  adhesions,  it  nevertheless  exposes  the 
patient  to  greater  operative  risk  than  simple  gastro- 
jejunostomy.  But,  as  we  said  when  dealing  with 
simple  ulcer  and  haemorrhagic  and  painful  ulcer,  to 
be  really  effective  and  to  give  a  durable  result, 
gastroenterostomy  should  be  combined  with  exclusion 
of  the  pylorus. 

In  point  of  fact,  in  the  majority  of  cases,  even 
should  a  stenosis  exist,  it  is  only  relative,  because 
most  frequently  it  is  produced  by  spasm.  A  time, 
therefore,  is  reached  when,  the  pylorus  becoming 
again  patent,  the  stoma  will  no  longer  be  utilised  and 
will  tend  to  become  occluded,  and  then  recurrences 
are  to  be  feared.  Consequently,  in  order  to  carry 
out  a  useful  interference  and  one  that  will  at  the  same 
time  be  durable,  gastroenterostomy  with  exclusion 
of  the  pylorus  should  be  done,  whose  technical 
difficulties  will  be  largely  compensated  by  the 
physiological  advantages  it  offers. 


CHAPTER  XVI 

TRAUMATIC     AFFECTIONS  I     CONTUSION,     WOUNDS 
AND    FOREIGN    BODIES    IN   THE   STOMACH 

Contusions. — In  comparison  with  other  abdominal 
viscera,  the  stomach  is  rather  infrequently  involved 
by  traumata.  Being  in  greater  part  protected  by  the 
lower  portion  of  the  thorax,  it  escapes  external 
violence  to  such  an  extent  that  out  of  a  total  of  112 
cases  of  serious  contusion  of  the  abdomen  Mackenzie 
only  found  one  instance  in  which  the  stomach  was 
involved.  The  exact  diagnosis  in  serious  cases  is  not 
always  possible.  Treatment  cannot  at  once  be 
directed  to  a  gastric  lesion  ;  it  is  indicated  by  general 
abdominal  symptoms,  and  in  the  majority  of  cases 
urgent  surgical  interference  will  be  required,  so  that 
it  will  be  imprudent,  not  to  say  rash,  to  delay  opera- 
tion until  a  differential  diagnosis  has  been  made. 

The  treatment  therefore  is  the  same  as  in  all 
abdominal  contusions.  The  operative  indications 
will  be  dictated  by  the  general  symptoms,  such  as  a 
weak  pulse,  respiratory  difficulty,  the  expression  of 
the  face,  and  locally  by  the  pain  on  pressure  and  on 
relaxing  the  pressure,  tense  abdominal  walls,  and  the 
development  of  an  area  of  dulness  in  the  flanks 
contrasting  with  the  tympanic  resonance  of  the  liver. 
These  various  symptoms  are  reasons  for  not  delaying 
operation,  although  we  must  admit,  as  we  have 


TRAUMATIC  AFFECTIONS  327 

previously  stated,  that  no  one  of  them  is  certain,  and 
that  the  serious  general  phenomena  as  well  as 
abdominal  rigidity  and  the  disappearance  of  the  liver 
dulness  do  not  infallibly  indicate  a  serious  lesion  of 
the  gastro-intestinal  tract. 

When  a  hsematemesis  arises  after  a  contusion  in  the 
epigastric  region  there  is  every  reason  to  suspect  that 
a  gastric  lesion  exists,  but  it  must  be  recalled  that 
this  symptom  is  by  no  means  one  of  certainty,  and 
that  one  may  be  easily  deceived  by  it.  But  whether 
or  not  a  serious  contusion  of  the  stomach  is 
diagnosed  or  only  a  suspicion  is  entertained  that 
some  visceral  lesion  exists  without  recognising  its 
exact  site,  peritonitis  is  to  be  feared,  and  if  the 
symptoms  outlined  above  are  present,  laparotomy 
should  be  resorted  to  without  delay. 

The  only  contra-indication  for  operation  is  shock, 
which  must  be  dealt  with  by  the  usual  means 
employed  to-day. 

However,  contusions  of  the  stomach  are  very 
variable  in  nature  from  other  lesions  that  they  may 
cause.  We  have  so  far  only  referred  to  serious  con- 
tusions with  immediate  perforation  of  the  stomach, 
but  very  frequently  the  traumatic  agent  will  not 
produce  such  important  or  alarming  disturbances  at 
once,  and  its  consequences  will  only  be  perceived  at  a 
later  date.  Thus,  besides  lacerations  or  complete 
perforations  giving  rise  to  local  or  general  peritonitis, 
one  may  observe  tears  involving  only  one  of  the 
strata  of  the  stomach  wall,  the  mucosa  only  or  the 
mucosa  and  muscular  stratum,  while  the  less  delicate 
serous  membrane  remains  intact. 


328  SURGICAL  TREATMENT 

The  traumatic  agent  may  also  produce  a  contusion 
of  the  gastric  wall  in  the  strict  sense  of  the  term,  that 
is  to  say,  a  simple  crushing  of  the  tissues  with  inter- 
stitial haemorrhage,  the  latter  being  sometimes  so 
extensive  as  to  form  haematomata,  which  in  turn 
become  readily  infected. 

These  lesions,  which  may  be  qualified  as  incom- 
plete, may  have  rather  rapidly  developing  conse- 
quences of  considerable  gravity,  such  as  secondary 
perforation,  which  may  arise  from  the  fourth  to  the 
eighth  day  following  the  receipt  of  the  injury,  or 
they  may  be  late  in  occurrence,  such  as  pyloric  or 
mid-gastric  stenosis  resulting  from  cicatricial  contrac- 
tion ;  and,  lastly,  a  gastric  ulcer  may  develop.  The 
latter  complication  of  gastric  contusion  is  not 
admitted  by  all.  In  reality  experimental  researches 
undertaken  in  this  direction  do  not  seem  to  be 
favourable  to  the  traumatic  origin  of  ulcer,  but 
clinical  data  are  in  our  possession  showing  the 
unquestioned  pathogenic  influence  of  contusion. 

In  a  former  chapter  we  pointed  out  that  these 
experimental  researches  were  valueless.  A  typical 
ulcer  has  never  been  produced  experimentally,  for  the 
very  good  reason  that  the  traumatism  must  be 
associated  with  hyperchlorhydria  in  order  to 
engender  ulcer.  Charles  Robin  insists  upon  the 
necessity  of  carefully  supervising  the  feeding  of  these 
contusion  cases  when  symptoms  of  hyperchlorhydria 
have  been  recognised,  and,  in  point  of  fact,  the  risk  of 
ulcer  formation  may  be  avoided  by  a  prophylactic 
treatment.  Hence  contusion  of  the  stomach,  accord- 
ing to  the  kind  of  lesion  produced,  may  have  as 


TRAUMATIC  AFFECTIONS  329 

consequences    complications    which    can    be    con- 
veniently classified  under  three  headings  : — 

(1)  Immediate  =  perforation  with  peritonitis. 

(2)  Delayed  =  incomplete  tear  or  even  crushing  with 
infiltration  giving  rise  to  secondary  perforation,  usually 
taking  place  from  four  to  eight  days  after  the  receipt  of 
the  injury. 

(3)  Late  =  crushing  or  incomplete  laceration,  which, 
according  to  the  gastric  area  in  which  the  lesion  is 
seated,  may  be  the  starting-point  of  an  inflammatory 
neoplasm,  a  stenosing  cicatrix,  or,  when  accompanied 
by  hyperchlorhydria,  ulcer. 

These  late  or  remote  lesions  should  teach  us  that 
in  gastric  traumata  we  should  not  merely  consider 
as  serious  those  cases  giving  rise  at  the  onset  to  peri- 
tonitis from  perforation.  All  cases  of  epigastric 
trauma  should  be  placed  under  careful  observation, 
which  is  the  only  means  by  which  one  may  detect  the 
early  symptoms  of  the  tardy  complications  above 
mentioned.  In  these  circumstances  an  internal  treat- 
ment can  be  commenced  at  the  very  onset  of  the 
symptoms,  and  in  many  cases  will  avoid  future 
trouble. 

As  to  the  surgical  treatment  of  these  complications, 
it  depends  upon  the  operative  indications  already 
studied  in  the  chapters  on  perforations,  stenoses, 
ulcers  and  perigastritides,  so  that  we  need  not  return 
to  this  subject.  We  have  already  said  that  in  the 
vast  majority  of  cases  it  is  impossible  to  foresee  the 
participation  of  the  stomach  in  abdominal  contusion, 
and  that  this  participation  adds  nothing  in  particular 
to  the  operative  indications  of  abdominal  traumata. 


830  SURGICAL  TREATMENT 

The  conduct  to  follow  can  therefore  be  decided  upon 
ahead. 

When  the  circumstances  are  such  that  laparotomy 
is  necessary  and  a  perforation  of  the  stomach  is  dis- 
covered the  treatment  is  simple  and  devoid  of  all 
discussion  :  the  wound  is  to  be  closed.  The  suture 
should  always  be  in  two  layers  with  a  second  row  of 
sutures  in  the  peritoneum  burying  the  first,  care 
being  exercised  not  to  deform  the  stomach.  If  this 
event  cannot  be  avoided,  particularly  if  it  results  in 
a  stenosis,  the  continuity  of  the  gastro-intestinal 
tract  must  be  maintained  by  gastroenterostomy. 

To  suture  a  wound  of  the  stomach  is  not  always  an 
easy  matter,  especially  when  one  has  to  work  in  the 
neighbourhood  of  the  cardia.  In  the  latter  circum- 
stance the  structures  to  be  reached  are  deep-seated, 
and  a  median  incision  is  usually  insufficient  for 
exposing  the  field  of  operation  adequately.  For  this 
reason  in  such  cases  it  is,  perhaps,  advantageous  to 
make  an  incision  parallel  with  the  left  costal  margin, 
or  even  to  create  a  larger  and  more  direct  approach 
by  employing  Savariaud's  transcostal  incision. 

Lesions  of  the  posterior  gastric  wall,  which  one 
should  never  neglect  to  verify,  although  they  are 
rather  uncommon  in  contusions,  are  to  be  exposed  by 
the  ordinary  transmesocolic  route  or  through  a 
gastrotomy  incision.  But  perhaps  the  best  route  of 
approach  is  by  Pauchet's  technique.  This  is  briefly 
as  follows  :  The  omentum  is  brought  out  and  turned 
backward,  and  then  with  the  point  of  a  knife  its 
insertion  with  the  transverse  colon  is  divided.  The 
intercolo-omental  detachment  is  continued  with  a 


TRAUMATIC  AFFECTIONS  331 

gauze  sponge  mounted  on  a  hsemostat.  The  onientum 
progressively  carries  the  stomach  upward  as  the 
detachment  proceeds  and  the  posterior  surface  of  the 
organ  appears.  If  there  is  a  perforation,  this  is  closed 
with  sutures  and  then  covered  by  omentum. 

All  things  considered,  closing  traumatic  perfora- 
tions of  the  stomach  is  usually  easier  to  carry  out 
than  suture  of  a  perforating  gastric  ulcer,  because  the 
edges  of  the  wound  are  formed  by  more  resistant  and 
softer  tissues,  which  are  not  so  easily  cut  through  by 
the  sutures.  The  edges  of  the  perforation  can  be 
easily  drawn  together  and  good  coaptation  obtained. 

As  to  peritonitis,  which  is  practically  bound  to 
occur,  it  should  be  treated  according  to  the  usual 
principles,  including  Fowler's  position.  All  the 
details  of  treatment  of  contusions  of  the  abdomen 
need  not  detain  us,  because  they  are  not  especially 
related  to  the  stomach. 

Wounds  of  the  Stomach. — Wounds  of  the  stomach, 
more  frequent  than  contusions  of  the  organ,  require 
the  same  treatment  and  offer  identically  the  same 
operative  indications  as  the  latter.  These  indications 
are  based  on  the  general  and  local  symptoms  that 
have  been  mentioned  in  contusions,  and  even  should 
they  all  not  be  apparent,  we  believe  that  operation 
should  not  be  delayed,  thus  losing  valuable  time. 

The  gravity  of  wounds  of  the  stomach  varies  very 
greatly  from  one  case  to  another,  according  to  their 
extent  and,  above  all,  according  to  the  degree  of 
repletion  of  the  organ  at  the  time  the  injury  is 
inflicted.  It  is  to  be  remarked,  however,  that  a  full 
stomach  does  not  always  empty  itself  through  the 


382  SURGICAL  TREATMENT 

wound,  especially  if  the  latter  be  small.  The  con- 
traction of  the  muscularis  tends  to  close  the  aperture, 
and  opposes  the  issue  of  the  gastric  contents.  But 
if  at  the  time  of  the  trauma  the  stomach  is  distended, 
a  missile,  even  of  small  calibre,  may,  if  its  velocity  be 
great,  produce  very  serious  lesions,  resulting  from  a 
sudden  increase  of  the  tension  of  the  intragastric 
fluid  mass.  Such  instances  are,  for  that  matter, 
uncommon. 

Stab  wounds  of  the  stomach  are  usually  simple, 
and  are  seated  in  the  anterior  wall  of  the  organ. 
Bullets  may  simply  perforate  the  anterior  wall,  or  the 
wound  caused  may  be  double.  Through-and-through 
perforation  is  common.  In  the  latter  case  the 
pancreas  is  often  traversed,  and  Willems  states  that 
during  the  war  he  has  frequently  found  the  missile 
embedded  behind  this  gland.  Kerr  has  recently 
operated  on  a  case  of  triple  wound  of  the  stomach 
caused  by  a  single  bullet,  which  at  the  same  time 
divided  the  right  ureter  after  entering  the  renal 
pelvis ;  it  then  made  three  perforations  in  the 
stomach,  the  first  about  5  centimetres  to  the  left  of 
the  pylorus  in  the  posterior  wall,  the  second  just 
opposite  in  the  anterior  wall,  while  the  third  perfora- 
tion was  just  above  the  other  two  in  the  lesser  curva- 
ture. The  latter  perforation  was  overlooked  ;  the 
patient  died  in  twenty  hours. 

All  the  regions  of  the  stomach  may  be  involved  in 
bullet  wounds.  When  the  trajectory  is  thoraco- 
abdominal  the  area  near  the  cardia  will  be  wounded. 
The  lesser  and  greater  curvatures  are  frequently  the 
site  of  lesions  which  are  complicated  by  free  haemor- 


TRAUMATIC  AFFECTIONS  333 

rhage  from  the  coronary  vessels.  Although  bullet 
wounds  of  the  stomach  may  be  the  only  ones  present, 
they  are  nevertheless  frequently  accompanied  by 
wounds  of  the  liver,  spleen,  transverse  colon  or  duo- 
denum, so  that  not  only  should  the  posterior  gastric 
wall  be  invariably  explored,  but  the  other  viscera  as 
well,  in  every  case  of  bullet  wound  of  the  stomach. 

It  is  to  be  remarked  that  very  often  the  exit 
aperture  in  the  stomach,  contrary  to  what  generally 
takes  place,  is  smaller  than  the  entrance  aperture. 
It  may  even  be  difficult  to  find  it,  as  occurred  in  a 
case  with  which  we  are  familiar.  In  this  patient  the 
entrance  aperture  measured  about  6  millimetres  in 
diameter,  while  that  in  the  posterior  wall  was  the 
size  of  a  pin's  head. 

As  to  treatment  of  wounds  of  the  stomach,  whether 
due  to  a  knife  or  bullet,  they  are  to  be  sutured,  which 
can  be  accomplished  without  much  difficulty  in 
many  cases.  The  onty  part  in  the  operation  which 
may  offer  some  difficulty  is  the  obtaining  of  sufficient 
exposure  in  which  to  work  easily.  More  frequently 
than  ulcer  or  contusion,  wounds  of  the  stomach  are 
seated  in  the  inaccessible  area  of  the  cardia.  The 
direction  of  the  trajectory  of  the  missile  or  that  of  the 
wound  will  give  a  fairly  good  indication  of  the 
probable  site  of  the  gastric  wound,  and  therefore, 
instead  of  making  a  median  incision,  Savariaud's 
transcostal  incision  can  be  made.  This  and  other 
similar  incisions  which  lead  directly  down  upon  the 
site  of  the  wound  have  been  found  most  satisfactory. 

The  results  of  operative  treatment  are  somewhat 
difficult  to  appreciate.  They  depend  essentially  on 


334  SURGICAL  TREATMENT 

the  time  that  has  elapsed  between  the  receipt  of  the 
injury  and  the  interference,  and  also,  in  a  large 
measure,  on  the  gravity  of  the  concomitant  lesions, 
in  particular  those  of  the  liver  and  pancreas. 

Untreated  wounds  of  the  stomach  have  been  known 
to  undergo  spontaneous  repair  accompanied  by 
the  recovery  of  the  patient.  Nevertheless  these 
spontaneous  recoveries  are  exceptions,  and  are 
explained  by  the  smallness  of  the  apertures  in  the 
gastric  walls,  the  small  amount  of  gastric  fluid 
making  its  exit  from  the  stomach  and  its  low  degree 
of  virulence.  It  is  always  preferable,  when  there  is 
good  reason  to  suppose  that  the  stomach  is  involved, 
to  operate,  and  to  operate  as  soon  as  possible,  that 
is  to  say,  as  soon  as  the  phenomena  of  shock  have 
subsided.  Shock  is  the  only  centra-indication  for 
immediate  operation,  and  is  in  itself  a  simple  matter, 
and  offers  no  danger  when  the  general  state  of  the 
subject  is  not  too  greatly  affected. 

Foreign  Bodies  in  the  Stomach. — The  most  varied 
objects  have  been  removed  from  the  stomach.  The 
most  frequent  are  copper  coins,  buttons  and  sets  of 
artificial  teeth,  which  are  met  with  almost  daily,  but 
very  curious  things  have  been  reported,  such  as  a 
bunch  of  nails,  broken  glass  or  even  forks.  It  is  of 
little  importance  to  know  how  these  objects  have 
been  swallowed  ;  it  is  evident  that  foreign  bodies 
of  such  different  natures  and  shapes  should  give  rise 
to  very  varied  disturbances.  Some  are  well  tolerated, 
to  such  a  degree  that  they  give  rise  to  no  symptom 
and  present  no  danger. 

It  is  even  remarkable  to  observe  how  tolerant  the 


TRAUMATIC  AFFECTIONS  335 

stomach  is  and  the  length  of  time  it  can  retain 
voluminous  objects  or  those  of  irregular  shape.  The 
organ  generally  adapts  itself  to  its  accidental  guest, 
and  places  it  in  a  position  which  hinders  it  the  least 
in  carrying  out  its  functions.  But  such  happy  events 
are  not  always  forthcoming,  and  a  foreign  body  may 
give  rise  to  serious  immediate  or  remote  consequences, 
especially  if  it  is  irregular  in  shape  with  sharp  edges 
or  asperities. 

Instances  of  acute  perforation  of  the  stomach  by 
foreign  bodies  are  too  well  known  to  require  descrip- 
tion, and  although  not  always  producing  this  compli- 
cation with  such  promptness,  they  may  determine 
serious  lesions,  resulting  in  tardy  complications, 
frequently  necessitating  operation. 

From  the  position  it  occupies  a  foreign  body  may 
obstruct  the  gastric  evacuation.  Embedded  in  the 
mucosa,  it  cannot  be  dislodged  by  the  movements 
of  the  stomach.  Finally,  the  resulting  ulceration 
of  the  mucosa  provokes  a  continual  irritation  of  the 
organ,  which  contracts  in  spasms,  as  does  the  bladder 
on  a  calculus.  If  this  process  of  irritation  over  a 
given  area  of  the  gastric  mucosa  is  constant,  ulcer 
of  the  mucosa  and  muscularis  will  ensue,  and  at 
length  the  serosa  will  in  turn  react.  The  latter 
contracts  adhesions  with  the  adjacent  viscera,  and 
these  adhesions  will  be  perforated  as  time  goes  on  ; 
thus,  in  some  rare  cases,  the  foreign  body  has  been 
spontaneously  eliminated  through  the  abdominal 
parietes  without  giving  rise  to  the  accentuated  pheno- 
mena of  peritonitis. 

However,  in  most  cases  the  migration  of  foreign 


336  SURGICAL  TREATMENT 

bodies  results  in  the  development  of  perigastric 
abscess  and  localised  peritonitis.  Hartmann's  case 
is  exceptional  in  which  a  fork  was  found  lying 
perfectly  free  among  the  coils  of  intestine,  and  only  a 
cicatrix  in  the  walls  of  the  stomach  testified  to  the 
passage  of  the  foreign  body  into  the  peritoneal 
cavity. 

Lastly,  a  foreign  body  may  be  the  remote  cause 
of  the  development  of  a  typical  peptic  ulcer,  as 
was  demonstrated  to  be  the  case  in  the  observa- 
tion related  by  Gould.  The  mere  fact  that  imme- 
diate complications  do  not  ensue  is  no  reason  to 
suppose  that  secondary  complications  will  not  arise, 
so  that  the  patient  should  be  invariably  kept  under 
close  observation  for  a  long  time.  It  is  of  the  utmost 
importance  to  ascertain  the  nature  and  above  all  the 
shape  of  the  foreign  body.  The  data  obtained  by 
the  anamnesis  are  often  indefinite,  so  that  fluoroscopy 
should  always  be  done,  which,  at  the  same  time,  will 
locate  the  situation  of  the  object  in  the  stomach. 

Malleable  bodies  with  rounded  surfaces  without 
asperities  may  sojourn  in  the  stomach  for  a  long 
time  without  giving  rise  to  any  apparent  disturb- 
ance. Consequently  a  certain  time  may  be  allowed 
to  elapse  before  deciding  upon  surgical  interference, 
as  no  very  serious  accident  is  liable  to  arise,  and  if 
later  on  gastric  disturbances  make  their  appearance, 
there  will  always  be  time  enough  to  proceed  with 
the  removal  of  the  provocative  agent. 

In  the  case  of  an  irregular  object  with  sharp  edges 
or  asperities  the  above-mentioned  complications  are 
prone  to  occur  suddenly,  and  rather  than  assume 


TRAUMATIC  AFFECTIONS  387 

any  risk,  even  if  no  symptom  exists  that  might 
lead  one  to  suppose  that  some  accident  is  to  occur 
sooner  or  later,  it  is  better  to  remove  the  foreign 
body  surgically.  Gastrotomy  presents  no  danger 
when  carried  out  in  these  circumstances,  but  when 
adhesions  have  been  allowed  to  form,  or  when  the 
foreign  body  is  on  the  point  of  perforating  the 
stomach,  the  operation  is  rendered  far  more  dangerous 
and  delicate. 


s.t. 


INDEX 


Adhesions,  cause  of  pain  in  gastric  ulcer,  259,  260 

or  bands,  pyloric  stenoses  from,  106 

post-operative,  in  gastroenterostomy,  39 — 41 

Anastomosis,  between  stomach  and  duodenum  in  operative  treatment  of 
gastric  ulcer,  189 

buttons,  various,  invention  of,  46,  47,  52 

indirect,  by  jejunum,  in  operative  treatment  of  gastric  ulcer,  189 

in  resection  operations,  procedures  of,  189 
Annular  gastrectomy,  64 

resection  for  mediogastric  stenosis,  114,  117 
Atony,  gastric,  complicating  gastroenterostomy,  43 

Balfour's  cautery  excision  of  gastric  ulcer,  66,  67 
Bands  or  adhesions,  pyloric  stenoses  from,  106 
Bardleben,  introduction  of  gastroplasty  by,  7 
Bassolo,  introduction  of  annular  gastrectomy  by,  64 
Billroth's  technique  in  pylorectomy,  55,  58,  59.  60 
Biiocular  stomach,  114 

common  after  burns  from  caustics,  96 
Biroher,  introduction  of  gastroplication  by,  7 
Braune,  introduction  of  duodenostomy  by,  13 
Brechot's  experiments  on  action  of  duodenal  secretions,  189 
Brenner's  views  in  favour  of  resection  of  stomach,  56,  57 
Buccal  infection  theory  of  pathogenesis  of  gastric  ulcer,  132 
Burns  from  caustics,  stenoses  due  to  cicatrices  from,  93 

severe,  involving  entire  mucosa  of  stomach,  operations  for,  97 

Cachexia,  degree  of,  factor  in  post-operative  shock  after  gastroenterestomy, 
45 

with  gastric  ulcer,  151 

Carle  and  Fantino's  views  on  disadvantage  of  pylorectomy,  78 
Caustics,  stenosis  due  to  cicatrices  of  burns  from,  93 
Cauterisation  and  curettage  in  treatment  of  hsemorrhagic  ulcer,  220 
Cautery  excision  of  gastric  ulcer,  66,  67 
Chantemesse's  theory  of  pathogenesis  of  gastric  ulcer,  123 
Chaput's  anastomosis  button,  52 
Cicatrised  ulcer  causing  stenosis,  70—73 
Clumsky's  study  on  gastroenterostomy,  23 
Coagulen  in  treatment  of  fulminating  hsemorrhagic  ulcer,  213 
Coll  in 's  statistics  on  situation  of  duodenal  ulcers,  71 
Congenital  stenosis  of  pylorus,  98 
Contusions  of  stomach,  326 
"  Corset  disease,"  286 
Corsets,  gastric  ptosis  and,  288,  289 

Curettage  and  cauterisation  in  treatment  of  hsemorrhagic  ulcer,  220 
Czerny,  introduction  of  pylorectomy  by.  54 

partial  resection  of  stomach,  56 

z  2 


840  INDEX 

Dahlgren's  views  on  direction  of  incision  in  gastroenterostomy,  26 

Deblet  and  Guibe"'s  researches  on  functions  of  stoma  in  patent  pylorus,  21 

Debove  and  Achard's  types  of  evolution  of  gastric  ulcer,  139 

Denans,  invention  of  anastomosis  button  by,  46 

Digestion,  influence  of  secretions  and  reflexes  of  duodenum  on,  189 

Dilatation  of  pylorus,  2 

Dilatation  of  stomach,  303—309 

idiopathic  or  atonic,  causes  of,  304 

nervous,  305 

congenital  predisposition  to,  305 
indications  for  surgical  treatment,  306 
operative  treatment  contra-indicated,  307,  308 

mechanical  or  organic,  303 

vertical,  284 

Doyen's  Y-shaped  technique  in  gastroenterostomy,  35,  37 
Duodenal  ulcer,  frequency  of,  compared  with  ulcer  of  stomach  or  pylorus,  71 
Duodenostomy,  13 
Duodenum,  secretions  and  reflexes  of,  influence  on  digestion,  189 

use  of,  for  anastomosis,  importance  of,  189 
Duret,  introduction  of  gastropexy  by,  5 
Dyspepsias,  nervous,  299 — 303 

failure  of  operative  treatment  in,  300,  301,  302 

secretions  in,  not  affected  by  operations,  302 
Dystopias,  gastric,  284—298 

Endocrine  origin  theory  of  pathogenesis  of  gastric  ulcer,  133 

Enterokinase,  secretion  of,  190 

Epigastric  point,  pain  at,  significance  of,  256 

Fats,  absorption  of,  decreased  by  gastroenterostomy  excluding  duodenum, 

190 
Finney's  gastroduodenostomy,  9 

operation  for  cicatricial  stenosis,  80 
Foreign  bodies  in  stomach,  334 — 337 
Friedmann's  endocrine  origin  theory  of  pathogenesis  of  gastric  ulcer,  133 

Gall-bladder,  pyloric  stenosis  from  bands  coming  from,  107 
Gastrectomy,  annular,  58,  64 
remote  results  of,  65 

lateral,  65 

transversal,  58 

difficulties  of  technique,  58 
Gastric  affections,  operative  indications,  67 — 69 

atony  complicating  gastroenterostomy,  43 

dystopias,  284—298 

juice,  action  of,  cause  of  gastric  ulcer,  126 

lavage  in  treatment  of  fulminating  haemorrhagic  ulcer,  213 

motility,  post-operative,  194 

secretion,  action  of  gastric  ulcer  on,  129 

tuberculosis,  chronic  form  of,  312 
Gastric  ulcer,  action  on  gastric  secretion,  129 

aetiology  of,  1 18 

and  syphilis,  relationship  between,  314 

cautery  excision  of,  66,  67 

chronic,  recurring  haemorrhage  sign  of  236,  237,  238 

clinical  forms  of,  145 

dimensions  of  lesion.  135 


INDEX  341 


Gastric  ulcer — contd. 
evolution  of,  139 

acute,  144 

chronic,  141 

"  normal,"  139 
frequency  of,  118 
friability  of  tissues  in,  136 
gastralgic,  149 
haemorrhagic,  147 

chronic,  latent,  206,  248 

indications  for  operation  in,  206 

recurring  type,  206,  236 

See  also  under  Haemorrhage, 
hyperchlorhydria  associated  with,  127 
latent,  152 

medical  treatment  of,  112,  143 
painful,  254—263 

association  with  neuropathy,  frequent,  257 

gastrolysis  in  treatment  of,  261 

medical  treatment  to  precede  operative,  261 

nature  and  causes  of  pain,  259,  260 

prognosis  of  treatment,  263 
pathogenesis  of,  121 — 134 

principal  and  secondary  causes,  131,  132 

theories  of,  121—134 

theory  of  autodigestion,  124,  125 
pathology  of,  134 
perforated,  264 

choice  of  operation,  276 

diagnostic  errors,  267 

evolution  of,  265,  266 

haemorrhage  preceding,  266 

importance  of  immediate  operation,  269 

peritonitis  in,  treatment  of,  282,  283 

phase  of  remission,  diagnostic  errors  during,  271 — 273 

phases  of,  270,  271 

recrudescence  of  symptoms  in,  265 

symptoms  of,  270 

time  to  operate,  274 

treatment  of,  268 

by  simple  drainage,  282 
resection,  277 

suture  or  obliteration  of  the  perforation,  278 
perforation  en  masse,  137 
recurrence  of,  explanation  of,  196 
regional  incidence  of,  120,  121 
sex  ratio  in,  120 
site  of,  frequency  statistics,  119 
syphilitic,  specific  treatment  in,  314,  315 
tuberculous,  appearances  of,  310,  311 

diagnostic  difficulties,  311 

frequency  and  site  of,  310 

sex  frequency  of,  311 

surgical  treatment  rarely  indicated,  312 
Gastric  ulcer,  typical,  146 

localisation  of,  method  of,  156 

medical  treatment  of,  duration  of,  154,  155 


342  INDEX 

Gastric  ulcer,  typical — contd. 
operations  in,  153 
operative  treatment  of,  advantages  of  gastroenterostomy,  192 

advantages  of  resection,  180 

choice  of  procedure,  179 

combination  of  resection  and  gastroenterostomy  operations,  202 

conclusions  regarding,  179 

disadvantages  of  gastroenterostomy,  200 

disadvantages  of  resection,  184 

effect  on  gastric  functions,  164 

effect  on  gastric  chemism,  170,  179 

indications  for  pylorectomy,  191,  192 

influence  on  gastric  motility,  165 

jejunostomy,  203 

mortality  statistics,  159 

necessity  for  post-operative  medical  treatment,  177 

remote  results,  160,  163 

results  of  (statistics),  161 

post-operative  treatment,  importance  of,  177,  179 
pyloric  localisation  of,  spasm  in,  157 
rapid  course  of,  in  young  subjects,  156 
stasis  in,  causes  of,  166 
with  cachexia,  151 
with  predominance  of  vomiting,  151 
Gastroanastomosis,  8 

for  mediogastric  stenosis,  114,  115 
Gastroduodenostomy,  8 

for  cicatricial  stenosis,  80 
for  pyloric  stenosis  from  adhesions,  1 13 
indications  for,  8,  9 
Gastroenterostomy,  15 

best  position  for  anastomotic  stoma,  23 

cause  of  defective  results  of,  85,  86 

closure  of  unutilised  stoma  as  cause  of  remote  defective  results,  86,  87 

dangers  and  disadvantages  of,  17 

dangers  of  Doyen's  and  Roux's  methods,  37 

development  of  operation,  16 

direct  effects  of,  89 

direction  of  gastric  incision,  views  upon,  25 — 28 

direction  of  intestinal  loop  in,  29 

effects  on  dilatation,  motility  and  capacity  of  stomach,  89,  90,  91 

effects  on  gastric  mucosa,  195 

gastric  atony  complicating,  43 

importance  of  peristalsis,  21,  30 

indications  for  one  of  Murphy's  buttons,  52 

in  treatment  of  cicatricial  pyloric  stenosis,  functional  results  of,  83 

of  cicatricial  pyloric  stenosis,  statistics  of  remote  results,  84 

congenital  pyloric  stenosis,  100 

of  gastric  ulcer,  advantages  of,  192 
disadvantages  of,  200 

of  gastroptosis,  296 

of  hsemorrhagic  ulcer,  226 — 232 

of  pyloric  stenosis,  82,  112,  113 

of  Reichmann's  disease,  324 

of  recurring  haemorrhagic  ulcer,  243 
isoperistalsis  in,  importance  of,  30 
length  of  anastomotic  loop,  30  ct  seq. 


INDEX  343 

Gastroenterostomy — contd. 

necessity  for  equal  incisions  in  stomach  and  intestine,  24 

necessity  for  exact  approximation  of  both  mucosa,  24 

peptic  ulcer  of  jejunum  complicating,  41 

position  of  anastomotic  stoma  as  cause  of  failure,  19 

posterior  anastomosis  supplanting  anterior,  20,  21 

posterior  transmesocolic  (von  Hacker's),  19 

post-operative  adhesions  complicating,  39 — 41 

pulmonary  complications  after,  45 

shock  after,  45 

simple,  defects  of,  197 

size  of  stoma,  23 

techniques  of  Roux  and  von  Hacker  contrasted,  198,  199 

use  of  Murphy's  button,  advantages  and  disadvantages,  48 — 51 

versus  resection  in  treatment  of  recurring  haemorrhagic  ulcer,  244 — 246 

vicious  circle  in,  17 

with  exclusion  of  pylorus,  advantages  of,  197 

with  exclusion  of  pylorus,  indications  for,  88 

in  treatment  of  chronic  latent  haemorrhagic  ulcer,  252 
with  pyloric  resection,  advantages  of,  203 
with  resection,  advantages  and  disadvantages  of,  202 
with  suture  of  perforation  in  treatment  of  perforated  gastric  ulcer,  280 
Gastro-jejunal  ulcer,  causes  of,  43 
Gastrojejunostomy,  15 
Gastrolysis,  5 

in  treatment  of  painful  gastric  ulcer,  261 
in  treatment  of  pyloric  stenosis  from  bands,  1 12 
Gastropexy,  5 

in  treatment  of  gastroptosis,  294 
modifications  in  technique  of,  6 
Gastroplasty,  7 

for  mediogastric  stenosis,  114,  115 
Gastroplication,  in  treatment  of  certain  cases  of  idiopathic  dilatation,  309 

techniques  of,  7 
Gastroptosis,  284 

and  neuropathic  states,  relationship  between,  291 
consequences  of,  290 
treatment  of,  medical,  292 

surgical,  choice  of  procedure,  293 
gastroenterostomy,  296 
gastropexy,  294 
indications  for,  293 

Gastrorrhagia  in  chronic  gastric  ulcers  with  slow  evolution,  248,  249 
Gastrotoray,  4 

in  treatment  of  haemorrhagic  ulcer,  217 
variations  in  technique  in,  4 
Girard's  modification  in  gastropexy,  6 

procedure  of  exclusion  of  pylorus,  88 
Glenard's  views  on  gastric  ptosis,  287 

Gould  (Pearce),  introduction  into  England  of  pyloroplasty  by,  3 
Guaiacum  reaction  in  faeces,  value  of,  in  differential  diagnosis  between  ulcer 
and  cancer,  149 

Haematemesis  in  contusions  of  stomach,  danger  of  peritonitis  from,  327 

Haemorrhage  in  gastric  ulcer,  chronic,  latent,  206,  248 
choice  of  operative  procedure,  250 
differential  diagnosis  from  malignant  disease,  249 


344  INDEX 

Haemorrhage  in  gastric  ulcer,  chronic,  latent — contd. 
indication  for  immediate  operation,  250 

treatment  of,  advantages  and  disadvantages  of  resection.  251,  252 
jejunostomy  in,  252 
summary  of,  253 

differential  diagnosis  of  simple  from  recurring,  240,  241 
indications  for  operation,  206 
preceding  perforation  of  gastric  ulcer,  266 
recurring  type,  206,  236 

choice  of  operative  procedure,  242 
indications  for  operation,  238,  242 
operative  treatment,  gastroenterostomy,  243 
jejunostomy,  247 
resection,  244,  246 
time  to  operate,  239,  240,  242 

superacute  or  fulminating,  character  of  ulcer  in  relation  to,  214 
choice  of  operation,  215,  216 
coagulen  in  treatment  of,  213 
curettage  and  cauterisation  in  treatment  of,  220 
dangers  of  operative  treatment,  210,  211 
indications  for  operation,  211,  212,  215 
mortality  statistics,  210 
operative  treatment,  206,  207 
gastroenterostomy,  226 — 232 
gastrotomy,  217 
infolding  the  ulcer,  222 
jejunostomy,  232 
ligature,  224 

resection  and  excision,  219 
views  on,  208,  209 
types  of,  147,  148,  149,  206 
Hahn's  method  of  dilatation  of  pylorus,  2 
Hartmann's  statistics  of  mortality  in  early  and  late  operations  for  cicatricial 

stenosis,  75 

Heinecke,  introduction  of  pyloroplasty  by,  3 
Heinecke-Mikulicz  poroplasty,  functional  results  after,  171,  172 
Hour-glass  stomach,  114 

Hyperacidity  chief  factor  in  causation  of  gastric  ulcer,  175 
Hypochlorhydria,  317 

associated  with  gastric  ulcer,  127 

effects  of  gastroenterostomy  in,  91 

simple,  317 

theories  regarding  pathogenesis  of,  318,  319 

Idiopathic  dilatation  of  stomach,  304 

Intestinal  loop  in  gastroenterostomy,  direction  of,  29 

Isoperlstalsis,  importance  of,  in  gastroenterostomy,  30 

Jaboulay's  anastomosis  button,  52 

method  of  dilatation  of  pylorus,  2 
Jejunostomy,  13 

in  treatment  of  chronic  latent  hsemorrhagic  ulcer,  252 
of  gastric  ulcer,  203 
of  hsemorrhagic  ulcer,  232 
of  recurring  hsemorrhagic  ulcer,  247 
of  severe  burns  of  stomach,  97 
variations  in  technique  for,  14 


INDEX  345 

Jejunum,  peptic  ulcer  of,  complicating  gastro-intestinal  anastomoses,  41 
Jonnesco's  technique  in  gastropexy,  5 

Katzenstein's  theory  of  pathogenesis  of  gastric  ulcer,  131 
Kelling's  researches  on  functions  of  stoma  in  patent  pylorus,  21 

views  on  length  of  anastomotic  loop  in  gastroenterostomy,  34 
Kidney,  movable,  causing  adhesions  producing  duodenal  or  pyloric  stenosis, 

108 

Kocher's  technique  in  pylorectomy,  55,  61 
Kbrte's  views  on  early  operation  for  pyloric  stenosis,  74 

Langenbuch's  technique  in  duodenostomy,  13 

Lennander's  experiments  on  sensibility  of  stomach  and  abdominal  viscera, 

254,  255 

Lerich's  technique  in  gastroduodenostomy,  9 
Letulle's  theory  of  pathogenesis  of  gastric  ulcer,  123 
Lewisohn's  experiments  on  value  of  pyloric  exclusion,  12 
Ligature  in  treatment  of  haemorrhagic  ulcer,  224 
Liver,  pyloric  stenosis  from  bands  coming  from,  107 
Locomotor  ataxia,  gastric  crises  in,  operative  treatment  in,  303 
Loretta,  introduction  of  dilatation  of  pylorus  by,  2 

introduction  of  gastrolysis  by,  5 
Liicke's  series  of  gastroenterostomies,  30 
Lucke-Rockwitz  technique  in  gastroenterostomy,  30 

Mayo,  W.  S.,  technique  in  exclusion  of  pylorus,  10 

Mayo-Robson's  method  of  dilatation  of  pylorus,  3 

Mediogastric  stenosis,  operations  for,  114 

Mikulicz  and  von  Leube's  views  on  indications  for  operative  treatment  of 

gastric  ulcer,  153 
Mikulicz's  statistics  on  results  of  pyloroplasty,  77 

technique  in  pyloroplasty,  3 

Monproflt's  views  on  indications  for  gastrotomy,  4 
Moynihan's  method  of  infolding  the  ulcer  in  treatment  of  haemorrhagic  ulcer, 

222 
technique  in  exclusion  of  pylorus,  10 

in  pylorectomy,  63 
Murphy's  button,  invention  of,  47 

use  of,  causing  gastro-jejunal  ulcer,  43 
disadvantages  and  dangers,  48 — 51 
indications  for,  52 
statistics,  48,  50 

Narcosis  length  of,  cause  of  pulmonary  complications  after  gastroenteros- 

tomy,  45 
Nervous  causes  of  gastric  stasis,  166 

dyspepsias,  299—303 
Nurslings,  pyloric  syndrome  of,  98,  100,  101 

Pain  in  gastric  ulcer,  varieties  and  significance  of,  149,  150 

in  simple  peptic  ulcer,  258 
Painful  gastric  ulcer,  254—263 

Pancreas,  adhesions  from,  causing  pyloric  stenosis,  108,  109 
Pauchet's  technique  in  lesions  of  posterior  gastric  wall,  330 
Paul's  method  of  dilatation  of  pylorus,  2 
Pavy's  theory  of  pathogenesis  of  gastric  ulcer,  124 
Pawlow's  experiments  on  effect  of  ulcer  on  gastric  secretions,  128 


346  INDEX 

Pean,  introduction  of  pylorectomy  by,  54 

Peptic  ulcer,  of  jejunum  complicating  gastro-intestinal  anastomoses,  41 

simple,  pain  in,  258 
Perforated  gastric  ulcer,  264 

Peristalsis,  importance  of,  in  gastroenterostomy,  21,  30 
Peritonitis  from  perforation  of  gastric  ulcer,  138,  267,  268 
Petersen's  views  on  length  of  anastomotic  loop  in  gastroenterostomy,  33,  34 
Petit,  J.  L.,  invention  of  anastomosis  button  by,  47 
Prepyloric  area,  ulcer  of,  danger  of  prolonged  medical  treatment,  156 
Prosecretine,  secretion  of,  190 
Ptosis,  gastric,  284 

pathogenesis  of,  286 

Pulmonary  complications  after  gastroenterostomy,  45 
Pylorectomy,  54 

early  mortality  statistics,  55 
for  cicatricial  stenosis,  81 

in  treatment  of  gastric  ulcer,  indications  for,  191 
method  of  termino-lateral  anastomosis,  63 
procedures  most  favoured,  62 

Pyloric  resection  with  gastroenterostomy,  advantages  of,  203 
Pyloric  stenosis,  cicatricial,  choice  of  operations  for,  92 

operations  for,  77,  111 
Pyloroplasty,  3 

danger  of  recurrence  of  stenosis  after,  79 
for  congenital  pyloric  stenosis,  technique  of,  104 — 106 
for  pyloric  stenosis,  77 
Pylorus,  blockage  of,  10 

congenital  stenosis  of,  diagnosis  of,  101 
hypertrophic,  101,  102 

mortality  from  operative  measures,  103 
pyloroplasty  for,  technique  of,  104 — 106 
spasm  producing,  101,  102 
symptoms  of,  99 
dilatation  of,  2 
exclusion  of,  9 
action  of,  11 

variations  in  technique,  10 
with  gastroenterostomy,  advantages  of,  197 
in  treatment  of  Reichmann's  disease,  325 

of  chronic  latent  hsemorrhagic  ulcer,  252 
hypertrophic  stenosis  of,  100 
patent,  functions  of  stoma  in,  researches  on,  21 
stenoses  of,  congenital,  98 

from  bands  or  adhesions,  106 
diagnosis  of,  110 
operative  treatment,  111 
indicating  gastroduodenostomy,  8 
tuberculosis  of  stenosing,  312,  313 
ulcer  of,  advantages  of  resection  operations  in,  188 
danger  of  prolonged  medical  treatment,  156 

Reichmann's  disease,  317 

classes  of  cases,  320 

theories  regarding  pathogenesis  of,  318,  319 

treatment  of,  choice  of  operation,  324 

gastroenterostomy  with  exclusion  of  pylorus,  324,  325 
indications  for  immediate  operation,  321.  322,  323 


INDEX  847 

Resection,  and  excision  in  treatment  of  haemorrhagic  ulcer,  219 

combined   with    gastroenterostomy,   advantages    and    disadvantages, 

202 

in  treatment  of  chronic  latent  haemorrhagic  ulcer,  advantages  of,  251 
in  treatment  of  gastric  ulcer,  advantages  of,  180 
disadvantages  of,  184 
types  of,  186 

in  treatment  of  perforated  gastric  ulcer,  277 
versus  gastroenterostomy  in  treatment  of  recurring  haemorrhagic  ulcer, 

244—246 

Resections,  various,  55 — 69 

Rieder  and  Leriche's  technique  in  annular  gastrectomy,  64 
Robin's  theory  of  pathogenesis  of  gastric  ulcer,  130 
Rokitansky,  Rindfleisch  and  Axel-Key's  theories  of  pathogenesis  of  gastric 

ulcer,  123 

Roux's  technique  in  gastroenterostomy,  35,  37 
Rovsing's  modification  of  Duret's  operation,  5 
Rutherford's  statistics  on  pyloroplasty,  78 
Rutkowski  and  Witzel's  method  of  gastroenterostomy  with  gastrostomy,  29 

Secretine,  formation  of,  190 
Secretions,  effects  of  operations  on,  171,  172 
gastric  disturbances  of,  316—325 
hyperchorhydria,  simple,  317 
hypochlorhydria,  317 

Senu,  invention  of  anastomosis  button  by,  46 
Sex  ratio  in  gastric  ulcer,  119 

in  tuberculous  gastric  ulcer,  311 
Shock,  operative,  after  gastroenterostomy,  45 
Socin's  procedure  in  gastroenterostomy,  31,  32 
Sonnenburg's  method  in  gastroenterostomy,  28 
Spasm  in  pyloric  ulcer,  danger  of,  157 

pyloric,  frequency  of,  during  evolution  of  gastric  ulcer,  166 
Stasis,  effects  of  gastroenterostomy  on,  89,  91 
gastric,  causes  of,  166 

consequences  of,  167,  168 

effects  of  various  operative  procedures  on,  168,  169 
Stenoses,  gastric.  70 
Stenosis,  congenital,  of  pylorus,  98 
from  cicatrised  ulcer,  70 — 73 

gastric,  due  to  cicatrices  of  burns  from  caustics,  93 
localisation  of,  94 
operative  measures  for,  96 
rapid  evolution  of,  95 
hypertrophic,  of  pylorus,  100 
mediogastric,  114 

operations  for,  114 

pyloric,  cicatricial,  advantages  of  early  operation,  74 
choice  of  operations  for,  92 
mortality  figures  in  early  and  late  operations,  75 
operative  indications,  73 
congenital,  clinical  forms  of,  98,  99 
from  bands  or  adhesions,  106 

coming  from  liver  and  gall-bladder,  107 
derived  from  transverse  colon,  108 
of  tuberculous  origin,  313 
operations  for,  76 


848  INDEX 

Stomach,  bilocular,  common  after  burns  from  caustics,  96 

condition  of,  in  idiopathic  dilatation,  306,  307 

contusions  of,  326 

complications  of,  329 
operative  treatment,  330 

dilatation,  motility  and  capacity  of,  effects  of  gastroenterostomy  on,  89, 
90,91 

dilatation  of,  303—309 

dystopias  of,  284 

foreign  bodies  in,  334 — 337 

insensitiveness  of,  254,  255 

operations  on,  classes  of,  1 

ptoses  of,  284 

resection  of,  partial,  Czerny's  introduction  of,  56 

syphilis  of,  310,  313 

traumatic  affections  of,  326 

tuberculosis  of,  310 — 315 
stenosing,  312 

vertical  dislocation  of,  284 

wounds  of,  331,  332 

treatment  of,  333 

Strauss'  pyloroplasty  for  congenital  pyloric  stenosis,  104 — 106 
Subphrenic  abscess  produced  by  perforated  gastric  ulcer,  268 
Surmay,  introduction  of  jejunostomy  by,  13 
Suture  material,  non-absorbable,  cause  of  gastro-jejunal  ulcer,  43 
Syphilis  and  gastric  ulcer,  relationship  between,  314 

of  stomach,  310,  313 

Thermocauterisation  of  gastric  ulcer,  187 

Thorax,  elongated,  causing  gastroptosis,  288 

Thoulke's  two-step  operation  of  gastroenterostomy  and  pylorectomy,  60 

Transverse  colon,  bands  from,  causing  pyloric  stenosis,  108 

Traumatic  affections  of  stomach,  326 

Troell's  statistics  of  operative  treatment  of  chronic  gastric  ulcer,  162 

Tuberculosis  of  stomach,  310 — 315 

chronic  form  of,  312 

stenosing,  312 

Tuffler  and  Reclus'  researches  on  functions  of  stoma  in  patent  pylorus, 
21 

Udadono's  statistics  regarding  operations  for  "  uncomplicated  "  gastric  ulcer ' 

163 
Ulcer,  cicatrised,  stenosis  from,  70 — 73 

gastric.     See  Gastric  ulcer. 

gastro-jejunal,  causes  of,  43 

peptic,  of  jejunum,  complicating  gastro-intestinal  anastomoses,  41 

Villar,  introduction  of  gastroduodenostomy  by,  8 
Virchow's  theory  of  pathogenesis  of  gastric  ulcer,  121 
Vomiting  in  congenital  pyloric  stenosis,  99 

in  gastric  ulcer,  151 
Von  Eiselsberg's  exclusion  of  pylorus,  9 

Von  Hacker's  posterior  transmesocolic  gastroenterostomy,  19,  32 
Von  Leube's  method  in  treatment  of  stenosis,  74 

Watson's  modification  in  gastroanastomosis,  8 

Weil  and  Pehu's  classification  of  congenital  pyloric  stenosis,  98,  99 


INDEX  849 

Woelfler,  introduction  of  gastroanastomosis  by,  8 

introduction  of  gastroenterostomy  by,  15,  19 

Women,  gastric  ulcers,  chronic,  less  amenable  to  medical  treatment  in,  155 
Wounds  of  stomach,  331,  332 

treatment  of,  333 

X-rays,  value  of,  in  diagnosis,  73 


WH1TSFH1AR1    PRI>S,    LID.,    LONDON    /LSD    TONBKlDei. 


Date  Due 


000  522  384  7 


WI  300 
C9Tls 
1921 
Cumston,  Charles  G 

Surgical  treatment  of  non- 
malignant  affections  of  the 
stomach. 


ISSUE  D  TO 


Charles  G 


VI  300 
C971s 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


